Scalp Block for Awake Craniotomy in a Patient With a Frontal Bone Mass: A Case Report

PubMed Central

Amiri, Hamid Reza; Kouhnavard, Marjan; Safari, Saeid

2012-01-01

“Anesthesia” for awake craniotomy is a unique clinical condition that requires the anesthesiologist to provide changing states of sedation and analgesia, to ensure optimal patient comfort without interfering with electrophysiologic monitoring and patient cooperation, and also to manipulate cerebral and systemic hemodynamics while guaranteeing adequate ventilation and patency of airways. Awake craniotomy is not as popular in developing countries as in European countries. This might be due to the lack of information regarding awake craniotomy and its benefits among the neurosurgeons and anesthetists in developing countries. From the economic perspective, this procedure may decrease resource utilization by reducing the use of invasive monitoring, the duration of the operation, and the length of postoperative hospital stay. All these reasons also favor its use in the developing world, where the availability of resources still remains a challenge. In this case report we presented a successful awake craniotomy in patient with a frontal bone mass. PMID:24904791

Potential for thermal damage to the blood–brain barrier during craniotomy: implications for intracortical recording microelectrodes

NASA Astrophysics Data System (ADS)

Shoffstall, Andrew J.; Paiz, Jen E.; Miller, David M.; Rial, Griffin M.; Willis, Mitchell T.; Menendez, Dhariyat M.; Hostler, Stephen R.; Capadona, Jeffrey R.

2018-06-01

Objective. Our objective was to determine how readily disruption of the blood–brain barrier (BBB) occurred as a result of bone drilling during a craniotomy to implant microelectrodes in rat cortex. While the phenomenon of heat production during bone drilling is well known, practices to evade damage to the underlying brain tissue are inconsistently practiced and reported in the literature. Approach. We conducted a review of the intracortical microelectrode literature to summarize typical approaches to mitigate drill heating during rodent craniotomies. Post mortem skull-surface and transient brain-surface temperatures were experimentally recorded using an infrared camera and thermocouple, respectively. A number of drilling conditions were tested, including varying drill speed and continuous versus intermittent contact. In vivo BBB permeability was assayed 1 h after the craniotomy procedure using Evans blue dye. Main results. Of the reviewed papers that mentioned methods to mitigate thermal damage during craniotomy, saline irrigation was the most frequently cited (in six of seven papers). In post mortem tissues, we observed increases in skull-surface temperature ranging from  +3 °C to  +21 °C, dependent on drill speed. In vivo, pulsed-drilling (2 s-on/2 s-off) and slow-drilling speeds (1000 r.p.m.) were the most effective methods we studied to mitigate heating effects from drilling, while inconclusive results were obtained with saline irrigation. Significance. Neuroinflammation, initiated by damage to the BBB and perpetuated by the foreign body response, is thought to play a key role in premature failure of intracortical recording microelectrodes. This study demonstrates the extreme sensitivity of the BBB to overheating caused by bone drilling. To avoid damage to the BBB, the authors recommend that craniotomies be drilled with slow speeds and/or with intermittent drilling with complete removal of the drill from the skull during ‘off’ periods. While saline alone was ineffective at preventing overheating, its use is still recommended to remove bone dust from the surgical site and to augment other cooling methods.

Berengario's drill: origin and inspiration.

PubMed

Chorney, Michael A; Gandhi, Chirag D; Prestigiacomo, Charles J

2014-04-01

Craniotomies are among the oldest neurosurgical procedures, as evidenced by early human skulls discovered with holes in the calvaria. Though devices change, the principles to safely transgress the skull are identical. Modern neurosurgeons regularly use electric power drills in the operating theater; however, nonelectric trephining instruments remain trusted by professionals in certain emergent settings in the rare instance that an electric drill is unavailable. Until the late Middle Ages, innovation in craniotomy instrumentation remained stunted without much documented redesign. Jacopo Berengario da Carpi's (c. 1457-1530 CE) text Tractatus de Fractura Calvae sive Cranei depicts a drill previously unseen in a medical volume. Written in 1518 CE, the book was motivated by defeat over the course of Lorenzo II de'Medici's medical care. Berengario's interchangeable bit with a compound brace ("vertibulum"), known today as the Hudson brace, symbolizes a pivotal device in neurosurgery and medical tool design. This drill permitted surgeons to stock multiple bits, perform the craniotomy faster, and decrease equipment costs during a period of increased incidence of cranial fractures, and thus the need for craniotomies, which was attributable to the introduction of gunpowder. The inspiration stemmed from a school of thought growing within a population of physicians trained as mathematicians, engineers, and astrologers prior to entering the medical profession. Berengario may have been the first to record the use of such a unique drill, but whether he invented this instrument or merely adapted its use for the craniotomy remains clouded.

Transorbital and transnasal endoscopic repair of a meningoencephalocele.

PubMed

Schaberg, Madeleine; Murchison, Ann P; Rosen, Marc R; Evans, James J; Bilyk, Jurij R

2011-10-01

A 71-year-old female with a history of thyroid eye disease (TED) presented for evaluation of a skull base mass noted on neuroimaging. She had previously undergone bilateral orbital decompressions and strabismus surgery and had no neurologic symptoms. Successful resection of the menigoencephalocele and repair of the skull base defect was performed through a combined transnasal endoscopic and transorbital approach, obviating the need for craniotomy.

Morphological Characterization of the Frontal and Parietal Bones of the Human Skull

DTIC Science & Technology

2017-03-01

ARL-TR- 7962 ● MAR 2017 US Army Research Laboratory Morphological Characterization of the Frontal and Parietal Bones of the...Army Research Laboratory Morphological Characterization of the Frontal and Parietal Bones of the Human Skull by Stephen L Alexander SURVICE...

Care of Pediatric Neurosurgical Patients in Iraq in 2007: Clinical and Ethical Experience of a Field Hospital

DTIC Science & Technology

2010-09-01

epidural abscess from a prior craniotomy for trauma at our facility. Patient Care Of the 42 pediatric patients seen in consultation, 28 required surgical...bifrontal craniotomy for the repair of an anterior skull base inju- ry (3 cases), decompressive craniectomy (5 cases), local debridement and wound closure...for PHI (10 cases), ICP monitoring only (4 cases), spinal instrumentation (1 case), spinal exploration/debridement with lumbar drainage for

One Small Randomly Blinking Dot in an Otherwise Dark Environment: Effects on Visual Cortical Neurons of Kittens.

DTIC Science & Technology

1982-06-23

back onto the tangent screen. A one centimeter oblong craniotomy was drilled, revealing the medial banks of both hemispheres, -2 mm posterior to A-P...zero. A one cm high plastic chamber was cemented to the skull around the craniotomy . After tungsten hooks were used to tear the dura over the medial...stimulus continuously for several weeks. If the kittens were awake for 10 hr per day average then each accumulated about 500 hr opportunity to view the

Immediate titanium mesh cranioplasty for treatment of post-craniotomy infections

PubMed Central

Wind, Joshua J.; Ohaegbulam, Chima; Iwamoto, Fabio M.; Black, Peter McL.; Park, John K.

2011-01-01

OBJECTIVE Post craniotomy infections have generally been treated by debridement of infected tissues, disposal of the bone flap, and delayed cranioplasty several months later to repair the resulting skull defect. Debridement followed by retention of the bone flap has also been advocated. Here we propose an alternative operative strategy for the treatment of post craniotomy infections. METHODS Two patients presenting with clinical and radiographic signs and symptoms of post craniotomy infections were treated by debridement, bone flap disposal, and immediate titanium mesh cranioplasty. The patients were subsequently administered antibiotics and their clinical courses were followed. RESULTS The patients treated in this fashion did not have recurrence of their infections during three-year follow-up periods. CONCLUSIONS Surgical debridement, bone flap disposal and immediate titanium mesh cranioplasty may be a suitable option for the treatment of post craniotomy infections. This treatment strategy facilitates the eradication of infectious sources and obviates the risks and costs associated with a second surgical procedure. PMID:22120410

Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases.

PubMed

Cassano, Michele; Felippu, Alexandre

2009-12-01

Endoscopic transnasal approaches to the skull base have revolutionized the treatment of cerebrospinal fluid (CSF) fistulae, making repair less invasive and more effective compared with craniotomy or extracranial techniques. This study evaluated, retrospectively, the results of endoscopic repair of dural defects with the use of mucoperiostal grafts taken from the lower turbinate. Between January 1997 and January 2007, 125 cases of anterior skull base CSF fistulae were treated endoscopically at the Instituto Felippu de Otorrinolaringologia, Sao Paolo, Brazil, and at the Department of Otolaryngology of the University Hospital "Ospedali Riuniti", Foggia, Italy. Fistula closure was achieved by overlay apposition of a lower turbinate mucoperiostal graft fixated with fibrin glue and Surgicell. The etiology of the fistula was accidental trauma in 41 cases, iatrogenic trauma in 29, skull base tumour in 12, and spontaneous in 43. The site of the defect was the sphenoid sinus in 43 patients, the cribriform plate in 42, the anterior ethmoid roof in 21, the posterior ethmoid roof in 17, and the posterior wall of the frontal sinus in 2. The success rate at first attempt was 94.4%; the 7 cases of postoperative recurrent CSF leakage involved patients presenting with spontaneous fistula and elevated intracranial pressure; 5 of these had a body-mass index > 30 and 3 suffered from diabetes mellitus. In our hands, the success rate of endoscopic fistula repair was high, even in defects larger than 2 cm. Success rates may be further improved with accurate diagnosis of elevated intracranial pressure, a contributing factor to failure of spontaneous fistula repair.

Incidence, Risk Factors and Consequences of Emergence Agitation in Adult Patients after Elective Craniotomy for Brain Tumor: A Prospective Cohort Study

PubMed Central

Chen, Lu; Xu, Ming; Li, Gui-Yun; Cai, Wei-Xin; Zhou, Jian-Xin

2014-01-01

Emergence agitation is a frequent complication that can have serious consequences during recovery from general anesthesia. However, agitation has been poorly investigated in patients after craniotomy. In this prospective cohort study, adult patients were enrolled after elective craniotomy for brain tumor. The sedation-agitation scale was evaluated during the first 12 hours after surgery. Agitation developed in 35 of 123 patients (29%). Of the agitated patients, 28 (80%) were graded as very and dangerously agitated. By multivariate stepwise logistic regression analysis, independent predictors for agitation included male sex, history of long-term use of anti-depressant drugs or benzodiazepines, frontal approach of the operation, method and duration of anesthesia and presence of endotracheal intubation. Total intravenous anesthesia and balanced anesthesia with short duration were protective factors. Emergence agitation was associated with self-extubation (8.6% vs 0%, P = 0.005). Sedatives were administered more in agitated patients than non-agitated patients (85.7% vs 6.8%, P<0.001). In conclusion, emergence agitation was a frequent complication in patients after elective craniotomy for brain tumors. The clarification of risk factors could help to identify the high-risk patients, and then to facilitate the prevention and treatment of agitation. For patients undergoing craniotomy, greater attention should be paid to those receiving a frontal approach for craniotomy and those anesthetized under balanced anesthesia with long duration. More researches are warranted to elucidate whether total intravenous anesthesia could reduce the incidence of agitation after craniotomy. Trial Registration ClinicalTrials.gov NCT00590499. PMID:25493435

Beyond the sniffer: frontal sinuses in Carnivora.

PubMed

Curtis, Abigail A; Van Valkenburgh, Blaire

2014-11-01

Paranasal sinuses are some of the most poorly understood features of mammalian cranial anatomy. They are highly variable in presence and form among species, but their function is not well understood. The best-supported explanations for the function of sinuses is that they opportunistically fill mechanically unnecessary space, but that in some cases, sinuses in combination with the configuration of the frontal bone may improve skull performance by increasing skull strength and dissipating stresses more evenly. We used CT technology to investigate patterns in frontal sinus size and shape disparity among three families of carnivores: Canidae, Felidae, and Hyaenidae. We provide some of the first quantitative data on sinus morphology for these three families, and employ a novel method to quantify the relationship between three-dimensional sinus shape and skull shape. As expected, frontal sinus size and shape were more strongly correlated with frontal bone size and shape than with the morphology of the skull as a whole. However, sinus morphology was also related to allometric differences among families that are linked to biomechanical function. Our results support the hypothesis that frontal sinuses most often opportunistically fill space that is mechanically unnecessary, and they can facilitate cranial shape changes that reduce stress during feeding. Moreover, we suggest that the ability to form frontal sinuses allows species to modify skull function without compromising the performance of more functionally constrained regions such as the nasal chamber (heat/water conservation, olfaction), and braincase (housing the brain and sensory structures). © 2014 Wiley Periodicals, Inc.

Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature.

PubMed

Shimony, Nir; Gonen, Lior; Shofty, Ben; Abergel, Avraham; Fliss, Dan M; Margalit, Nevo

2017-10-01

Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection. We retrospectively collected all patients with skull-base chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed. Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus. Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.

Supraorbital keyhole surgery for optic nerve decompression and dura repair.

PubMed

Chen, Yuan-Hao; Lin, Shinn-Zong; Chiang, Yung-Hsiao; Ju, Da-Tong; Liu, Ming-Ying; Chen, Guann-Juh

2004-07-01

Supraorbital keyhole surgery is a limited surgical procedure with reduced traumatic manipulation of tissue and entailing little time in the opening and closing of wounds. We utilized the approach to treat head injury patients complicated with optic nerve compression and cerebrospinal fluid leakage (CSF). Eleven cases of basal skull fracture complicated with either optic nerve compression and/or CSF leakage were surgically treated at our department from February 1995 to June 1999. Six cases had primary optic nerve compression, four had CSF leakage and one case involved both injuries. Supraorbital craniotomy was carried out using a keyhole-sized burr hole plus a small craniotomy. The size of craniotomy approximated 2 x 3 cm2. The optic nerve was decompressed via removal of the optic canal roof and anterior clinoid process with high-speed drills. The defect of dura was repaired with two pieces of tensa fascia lata that were attached on both sides of the torn dural defect with tissue glue. Seven cases with optic nerve injury included five cases of total blindness and two cases of light perception before operation. Vision improved in four cases. The CSF leakage was stopped successfully in all four cases without complication. As optic nerve compression and CSF leakage are skull base lesions, the supraorbital keyhole surgery constitutes a suitable approach. The supraorbital keyhole surgery allows for an anterior approach to the skull base. This approach also allows the treatment of both CSF leakage and optic nerve compression. Our results indicate that supraorbital keyhole operation is a safe and effective method for preserving or improving vision and attenuating CSF leakage following injury.

Rapid and minimum invasive functional brain mapping by real-time visualization of high gamma activity during awake craniotomy.

PubMed

Ogawa, Hiroshi; Kamada, Kyousuke; Kapeller, Christoph; Hiroshima, Satoru; Prueckl, Robert; Guger, Christoph

2014-11-01

Electrocortical stimulation (ECS) is the gold standard for functional brain mapping during an awake craniotomy. The critical issue is to set aside enough time to identify eloquent cortices by ECS. High gamma activity (HGA) ranging between 80 and 120 Hz on electrocorticogram is assumed to reflect localized cortical processing. In this report, we used real-time HGA mapping and functional neuronavigation integrated with functional magnetic resonance imaging (fMRI) for rapid and reliable identification of motor and language functions. Four patients with intra-axial tumors in their dominant hemisphere underwent preoperative fMRI and lesion resection with an awake craniotomy. All patients showed significant fMRI activation evoked by motor and language tasks. During the craniotomy, we recorded electrocorticogram activity by placing subdural grids directly on the exposed brain surface. Each patient performed motor and language tasks and demonstrated real-time HGA dynamics in hand motor areas and parts of the inferior frontal gyrus. Sensitivity and specificity of HGA mapping were 100% compared with ECS mapping in the frontal lobe, which suggested HGA mapping precisely indicated eloquent cortices. We found different HGA dynamics of language tasks in frontal and temporal regions. Specificities of the motor and language-fMRI did not reach 85%. The results of HGA mapping was mostly consistent with those of ECS mapping, although fMRI tended to overestimate functional areas. This novel technique enables rapid and accurate identification of motor and frontal language areas. Furthermore, real-time HGA mapping sheds light on underlying physiological mechanisms related to human brain functions. Copyright © 2014 Elsevier Inc. All rights reserved.

Adaptive Focusing For Ultrasonic Transcranial Brain Therapy: First In Vivo Investigation On 22 Sheep

NASA Astrophysics Data System (ADS)

Pernot, Mathieu; Aubry, Jean-François; Tanter, Mickael; Boch, Anne Laure; Kujas, Michelle; Fink, Mathias

2005-03-01

A high power prototype dedicated to trans-skull therapy has been tested in vivo on 22 sheep. The array is made of 300 high power transducers working at 1MHz central frequency and is able to achieve 400 bars at focus in water during five seconds with a 50% percent duty cycle. In the first series of experiments, 10 sheep were treated and sacrificed immediately after treatment. A complete craniotomy was performed on half of the treated animal models in order to get a reference model. On the other half, minimally invasive surgery has been performed: a hydrophone was inserted at a given target location inside the brain through a craniotomy of a few mm2. A time reversal experiment was then conducted through the skull bone with the therapeutic array to treat the targeted point. Thanks to the high power technology of the prototype, trans-skull adaptive treatment could be achieved. In a second series of experiments, 12 animals were divided into three groups and sacrificed respectively one, two or three weeks after treatment. Finally, Magnetic Resonance Imaging and histological examination were performed to confirm tissue damage.

Ultrasonic brain therapy: First trans-skull in vivo experiments on sheep using adaptive focusing

NASA Astrophysics Data System (ADS)

Pernot, Mathieu; Aubry, Jean-Francois; Tanter, Michael; Fink, Mathias; Boch, Anne-Laure; Kujas, Michèle

2004-05-01

A high-power prototype dedicated to trans-skull therapy has been tested in vivo on 20 sheep. The array is made of 200 high-power transducers working at 1-MHz central and is able to reach 260 bars at focus in water. An echographic array connected to a Philips HDI 1000 system has been inserted in the therapeutic array in order to perform real-time monitoring of the treatment. A complete craniotomy has been performed on half of the treated animal models in order to get a reference model. On the other animals, a minimally invasive surgery has been performed thanks to a time-reversal experiment: a hydrophone was inserted at the target inside the brain thanks to a 1-mm2 craniotomy. A time-reversal experiment was then conducted through the skull bone with the therapeutic array to treat the targeted point. For all the animals a specified region around the target was treated thanks to electronic beam steering. Animals were finally divided into three groups and sacrificed, respectively, 0, 1, and 2 weeks after treatment. Finally, histological examination confirmed tissue damage. These in vivo experiments highlight the strong potential of high-power time-reversal technology.

Management of Dropped Skull Flaps.

PubMed

Abdelfatah, Mohamed AbdelRahman

2017-01-01

Dropping a skull flap on the floor is an uncommon and avoidable mistake in the neurosurgical operating theater. This study retrospectively reviewed all incidents of dropped skull flaps in Ain-Shams University hospitals during a 10-year period to show how to manage this problem and its outcome. Thirty-one incidents of dropped skull flaps occurred from January 2004 to January 2014 out of more than 10,000 craniotomies. Follow-up period varied from 20 to 44 months. The bone flap was dropped while elevating the bone (n = 16), while drilling the bone on the operating table (n = 5), and during insertion of the bone flap (n = 10). Treatment included re-insertion of the skull flap after soaking it in povidone iodine and antibiotic solution (n = 17) or after autoclaving (n = 11), or discarding the skull flap and replacing it with a mesh cranioplasty in the same operation (n = 3). No bone or wound infection was noted during the follow-up period. Management of dropped skull flap is its prevention. Replacement of the skull flap, after decontamination, is an option that avoids the expense and time of cranioplasty.

A large, switchable optical clearing skull window for cerebrovascular imaging

PubMed Central

Zhang, Chao; Feng, Wei; Zhao, Yanjie; Yu, Tingting; Li, Pengcheng; Xu, Tonghui; Luo, Qingming; Zhu, Dan

2018-01-01

Rationale: Intravital optical imaging is a significant method for investigating cerebrovascular structure and function. However, its imaging contrast and depth are limited by the turbid skull. Tissue optical clearing has a great potential for solving this problem. Our goal was to develop a transparent skull window, without performing a craniotomy, for use in assessing cerebrovascular structure and function. Methods: Skull optical clearing agents were topically applied to the skulls of mice to create a transparent window within 15 min. The clearing efficacy, repeatability, and safety of the skull window were then investigated. Results: Imaging through the optical clearing skull window enhanced both the contrast and the depth of intravital imaging. The skull window could be used on 2-8-month-old mice and could be expanded from regional to bi-hemispheric. In addition, the window could be repeatedly established without inducing observable inflammation and metabolic toxicity. Conclusion: We successfully developed an easy-to-handle, large, switchable, and safe optical clearing skull window. Combined with various optical imaging techniques, cerebrovascular structure and function can be observed through this optical clearing skull window. Thus, it has the potential for use in basic research on the physiopathologic processes of cortical vessels. PMID:29774069

Awake craniotomy for tumor resection.

PubMed

Attari, Mohammadali; Salimi, Sohrab

2013-01-01

Surgical treatment of brain tumors, especially those located in the eloquent areas such as anterior temporal, frontal lobes, language, memory areas, and near the motor cortex causes high risk of eloquent impairment. Awake craniotomy displays major rule for maximum resection of the tumor with minimum functional impairment of the Central Nervous System. These case reports discuss the use of awake craniotomy during the brain surgery in Alzahra Hospital, Isfahan, Iran. A 56-year-old woman with left-sided body hypoesthesia since last 3 months and a 25-year-old with severe headache of 1 month duration were operated under craniotomy for brain tumors resection. An awake craniotomy was planned to allow maximum tumor intraoperative testing for resection and neurologic morbidity avoidance. The method of anesthesia should offer sufficient analgesia, hemodynamic stability, sedation, respiratory function, and also awake and cooperative patient for different neurological test. Airway management is the most important part of anesthesia during awake craniotomy. Tumor surgery with awake craniotomy is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit.

Awake craniotomy for tumor resection

PubMed Central

Attari, Mohammadali; Salimi, Sohrab

2013-01-01

Surgical treatment of brain tumors, especially those located in the eloquent areas such as anterior temporal, frontal lobes, language, memory areas, and near the motor cortex causes high risk of eloquent impairment. Awake craniotomy displays major rule for maximum resection of the tumor with minimum functional impairment of the Central Nervous System. These case reports discuss the use of awake craniotomy during the brain surgery in Alzahra Hospital, Isfahan, Iran. A 56-year-old woman with left-sided body hypoesthesia since last 3 months and a 25-year-old with severe headache of 1 month duration were operated under craniotomy for brain tumors resection. An awake craniotomy was planned to allow maximum tumor intraoperative testing for resection and neurologic morbidity avoidance. The method of anesthesia should offer sufficient analgesia, hemodynamic stability, sedation, respiratory function, and also awake and cooperative patient for different neurological test. Airway management is the most important part of anesthesia during awake craniotomy. Tumor surgery with awake craniotomy is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit. PMID:24223378

Responsiveness in Behaving Monkeys and Human Subjects

DTIC Science & Technology

1993-07-31

Status of Current Research - Statement of Work Each study involving awake , behaving monkey neurophysiological recording used a behavioral paradigm that...anesthesia. A craniotomy was performed at approximately A+ 14.5mm. The recording chamber then was fixed to the skull at a lateral angle of 8’ from

Model-based surgical planning and simulation of cranial base surgery.

PubMed

Abe, M; Tabuchi, K; Goto, M; Uchino, A

1998-11-01

Plastic skull models of seven individual patients were fabricated by stereolithography from three-dimensional data based on computed tomography bone images. Skull models were utilized for neurosurgical planning and simulation in the seven patients with cranial base lesions that were difficult to remove. Surgical approaches and areas of craniotomy were evaluated using the fabricated skull models. In preoperative simulations, hand-made models of the tumors, major vessels and nerves were placed in the skull models. Step-by-step simulation of surgical procedures was performed using actual surgical tools. The advantages of using skull models to plan and simulate cranial base surgery include a better understanding of anatomic relationships, preoperative evaluation of the proposed procedure, increased understanding by the patient and family, and improved educational experiences for residents and other medical staff. The disadvantages of using skull models include the time and cost of making the models. The skull models provide a more realistic tool that is easier to handle than computer-graphic images. Surgical simulation using models facilitates difficult cranial base surgery and may help reduce surgical complications.

Annual Research Progress Report. 1 October 1977-30 September 1978.

DTIC Science & Technology

1978-09-30

requiring craniotomy , one open skull frac- ture, one cervical spine fracture, two quadraplegic patients and seven patients with an acute brain...attempt of aspiration is made. Although the blood is available by gravity drainage , this is not ideal for short collections periods. Further work on the

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps.

PubMed

Archer, Jacob B; Sun, Hai; Bonney, Phillip A; Zhao, Yan Daniel; Hiebert, Jared C; Sanclement, Jose A; Little, Andrew S; Sughrue, Michael E; Theodore, Nicholas; James, Jeffrey; Safavi-Abbasi, Sam

2016-03-01

This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)--1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Astrocyte activation and wound healing in intact-skull mouse after focal brain injury.

PubMed

Suzuki, Takayuki; Sakata, Honami; Kato, Chiaki; Connor, John A; Morita, Mitsuhiro

2012-12-01

Localised brain tissue damage activates surrounding astrocytes, which significantly influences subsequent long-term pathological processes. Most existing focal brain injury models in rodents employ craniotomy to localise mechanical insults. However, the craniotomy procedure itself induces gliosis. To investigate perilesional astrocyte activation under conditions in which the skull is intact, we created focal brain injuries using light exposure through a cranial window made by thinning the skull without inducing gliosis. The lesion size was maximal at ~ 12 h and showed substantial recovery over the subsequent 30 days. Two distinct types of perilesional reactive astrocyte, identified by GFAP upregulation and hypertrophy, were found. In proximal regions the reactive astrocytes proliferated and expressed nestin, whereas in regions distal to the injury core the astrocytes showed increased GFAP expression but did not proliferate, lacked nestin expression, and displayed different morphology. Simply making the window did not induce any of these changes. There were also significant numbers of neurons in the recovering cortical tissue. In the recovery region, reactive astrocytes radially extended processes which appeared to influence the shapes of neuronal nuclei. The proximal reactive astrocytes also formed a cell layer which appeared to serve as a protective barrier, blocking the spread of IgG deposition and migration of microglia from the lesion core to surrounding tissue. The recovery was preceded by perilesional accumulation of leukocytes expressing vascular endothelial growth factor. These results suggest that, under intact skull conditions, focal brain injury is followed by perilesional reactive astrocyte activities that foster cortical tissue protection and recovery. © 2012 Federation of European Neuroscience Societies and Blackwell Publishing Ltd.

Combined treatment of advanced stages of recurrent skin cancer of the head.

PubMed

Pompucci, Angelo; Rea, Giancarla; Farallo, Eugenio; Salgarello, Marzia; Campanella, Antonino; Fernandez, Eduardo

2004-04-01

The authors investigated whether skull base resection and primary free-flap reconstruction in a single-stage surgery is oncologically effective for treating advanced stages of recurrent skin cancer (RSC) of the head. Eighteen consecutive patients were surgically treated. Twelve of them underwent an anterolateral skull base resection, which was performed using a pterional craniotomy combined with an orbitozygomatic osteotomy. Six patients underwent a posterolateral skull base resection, which was performed using an asterional craniotomy combined with a retrolabyrinthine petrosectomy. The wide postoperative defects were covered with muscular or myocutaneous free flaps. The main factor influencing survival was the extent of the resection: patients with no or minimal residual disease showed a statistically significant longer survival time than those with consistent residual disease. Basal cell carcinoma had a better prognosis than squamous cell carcinoma. A trend toward improved survival was observed in patients classified as T4M0 with negative lymph nodes (N0), but this trend was not statistically significant. Adjuvant radiotherapy significantly influenced both survival time and the rate of local recurrence. The surgical morbidity rate was 27.8%; there were two transient cerebrospinal fluid leaks and three seventh cranial nerve injuries. Late complications included radionecrosis in one patient and skin erosion requiring a second surgery in another patient. No deaths occurred during a 30-day postoperative period. Advances in skull base surgery and free-flap reconstruction allowed the authors to treat patients with advanced-stage RSC of the head in a rather satisfactory manner. Only when it is impossible to achieve no or minimal residual disease should aggressive treatment be considered.

Reconstruction of the anterior skull base after major trauma or extensive tumour resection.

PubMed

König, Stefan Alexander; Ranguis, Sebastian; Gramlich, Veronika; Spetzger, Uwe

2015-01-01

The authors describe their experience with the reconstruction of complex anterior skull base defects after trauma or tumour resection using a "sandwich" technique with pericranial flap, titanium mesh and TachoSil. Description of surgical anatomy, surgical technique, indications, limitations, complications, specific perioperative considerations and specific information to give to the patient about surgery and potential risks. A summary of ten key points is given. After a bifrontal craniotomy and a subfrontal approach, it is possible to achieve a reliable reconstruction of the anterior skull base in a watertight manner by fixing a pericranial flap or a fascia lata graft to the orbital roofs and planum sphenoidale with an individually tailored titanium mesh and closing the frontobasal dura leasion with TachoSil.

A novel classification of frontal bone fractures: The prognostic significance of vertical fracture trajectory and skull base extension.

PubMed

Garg, Ravi K; Afifi, Ahmed M; Gassner, Jennifer; Hartman, Michael J; Leverson, Glen; King, Timothy W; Bentz, Michael L; Gentry, Lindell R

2015-05-01

The broad spectrum of frontal bone fractures, including those with orbital and skull base extension, is poorly understood. We propose a novel classification scheme for frontal bone fractures. Maxillofacial CT scans of trauma patients were reviewed over a five year period, and frontal bone fractures were classified: Type 1: Frontal sinus fracture without vertical extension. Type 2: Vertical fracture through the orbit without frontal sinus involvement. Type 3: Vertical fracture through the frontal sinus without orbit involvement. Type 4: Vertical fracture through the frontal sinus and ipsilateral orbit. Type 5: Vertical fracture through the frontal sinus and contralateral or bilateral orbits. We also identified the depth of skull base extension, and performed a chart review to identify associated complications. 149 frontal bone fractures, including 51 non-vertical frontal sinus (Type 1, 34.2%) and 98 vertical (Types 2-5, 65.8%) fractures were identified. Vertical fractures penetrated the middle or posterior cranial fossa significantly more often than non-vertical fractures (62.2 v. 15.7%, p = 0.0001) and had a significantly higher mortality rate (18.4 v. 0%, p < 0.05). Vertical fractures with frontal sinus and orbital extension, and fractures that penetrated the middle or posterior cranial fossa had the strongest association with intracranial injuries, optic neuropathy, disability, and death (p < 0.05). Vertical frontal bone fractures carry a worse prognosis than frontal bone fractures without a vertical pattern. In addition, vertical fractures with extension into the frontal sinus and orbit, or with extension into the middle or posterior cranial fossa have the highest complication rate and mortality. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Orbitopterional Craniotomy Resection of Pediatric Suprasellar Craniopharyngioma.

PubMed

LeFever, Devon; Storey, Chris; Guthikonda, Bharat

2018-04-01

The orbitopterional approach provides an excellent combination of basal access and suprasellar access. This approach also allows for less brain retraction when resecting larger suprasellar tumors that are more superiorly projecting due to a more frontal and inferior trajectory. In this operative video, the authors thoroughly detail an orbitopterional craniotomy utilizing a one-piece modified orbitozygomatic technique. This technique involves opening the craniotomy through a standard pterional incision. The craniotomy is performed using the standard three burr holes of a pterional approach; however, the osteotomy is extended anteriorly through the frontal process of the zygomatic bone as well as through the supraorbital rim. In this operative video atlas, the authors illustrate the operative anatomy, as well as surgical strategy and techniques to resect a large suprasellar craniopharyngioma in a 4-year-old male. Other reasonable approach options for a lesion of this size would include a standard pterional approach, a supraorbital approach, or expanded endoscopic transsphenoidal approach. The lesion was quite high and thus, the supraorbital approach may confine access to the superior portion of the tumor. While recognizing that some groups may have chosen the endoscopic expanded transsphenoidal approach for this lesion, the authors describe more confidence in achieving the goal of a safe and maximal resection with the orbitopterional approach. The link to the video can be found at: https://youtu.be/eznsK16BzR8 .

Pain during awake craniotomy for brain tumor resection. Incidence, causes, consequences and management.

PubMed

Fontaine, D; Almairac, F

2017-06-01

Awake craniotomy for brain tumor resection is usually well-tolerated and most of the patients are satisfied. However, in studies reporting the patients' postoperative perception of the awake craniotomy procedure, about half of them have experienced some degree of intraoperative pain. Pain was mild (intensity between 1 and 2 on the visual analogical score) short lasting in most cases, and did not challenge the procedure. Pain was reported as moderate in about 25% and exceptionally severe. We conducted a preliminary survey among French centers (n=9) routinely performing awake craniotomy. Neurosurgeons' opinions were concordant with patient's reports. Intraoperative pain exceptionally challenged the awake craniotomy procedure or led to changes in the resection strategy. For neurosurgeons, the most challenging causes of intraoperative pain were the patient's inadequate installation, the contact of surgical tools with pain-sensitive intracranial structures, especially the dura mater of the skull base, falx cerebri, and the leptomeninges of the lateral fissure and neighboring sulci. Strategies to deal with these causes included focusing the patient on the intraoperative functional tests to distract their attention away from the pain, and avoiding contacts with the pain-sensitive intracranial structures during the awake phase. Adequate preoperative patient information and preparation, trained anesthesiologists and application of recommendations for awake craniotomy procedures as well as adaptation of surgical technique to avoid contact with pain-sensitive intracranial structures are key factors to prevent intraoperative pain and ensure patient's postoperative satisfaction. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

[Three cases of an intracranial wooden foreign body].

PubMed

Fujimoto, S; Onuma, T; Amagasa, M; Okudaira, Y

1987-07-01

Three cases of intracranial wooden foreign body are reported discussing the diagnostic and therapeutic problems. First case is a 50-year-old man. After drinking, he drove a bike and fell to the ground. On admission the wooden foreign body could not been detected in appearance. CT scan showed low density area similar to air in bilateral anterior horn of lateral ventricle. The patient was treated for traumatic pneumocephalus at first. Later, it proved that he was stabbed with a foreign body penetrating into the contralateral frontal lobe through the left nasal cavity. It was extracted by endonasal approach by otolaryngologist, fortunately without trouble. The foreign body was a branch of tree. The second case is an 18-year-old man. He was driving a car, and suffered injury. He was stabbed with a wooden stake penetrating into his left eye. Immediately, bifrontal craniotomy was performed and the stake was withdrawn carefully. Moreover bone fragments were removed. The third case is a 61-year-old man. When he cut the timber by chain saw, a piece of wood hit and stabbed his right eye directly. Immediately right front temporal craniotomy was performed. The piece of wood was withdrawn from the right eye, and pieces of glass, wood and bone fragments were evacuated. It is difficult to confirm intracranial foreign body accurately by means of only plain skull film and usual CT scans. It is necessary to utilize various function of CT scanner. For example, it is useful to know CT values or select measure mode with window width and level or make reconstruction image to sagittal or coronal section, and so on.(ABSTRACT TRUNCATED AT 250 WORDS)

Conscious sedation for awake craniotomy in intraoperative magnetic resonance imaging operating theater

PubMed Central

Takrouri, Mohamad Said Maani; Shubbak, Firas A.; Al Hajjaj, Aisha; Maestro, Rolando F. Del; Soualmi, Lahbib; Alkhodair, Mashael H.; Alduraiby, Abrar M.; Ghanem, Najeeb

2010-01-01

This case report describes the first case in intraoperative magnetic resonance imaging operating theater (iMRI OT) (BrainSuite®) of awake craniotomy for frontal lobe glioma excision in a 24-year-old man undergoing eloquent cortex language mapping intraoperatively. As he was very motivated to take pictures of him while being operated upon, the authors adapted conscious sedation technique with variable depth according to Ramsey's scale, in order to revert to awake state to perform the intended neurosurgical procedure. The patient tolerated the situation satisfactorily and was cooperative till the finish, without any event. We elicit in this report the special environment of iMRI OT for lengthy operation in pinned fixed patient having craniotomy. PMID:25885085

[Anatomy and imaging study of a new upper-agger nasi pathway of frontal sinus surgery].

PubMed

Liu, Zhixian; Li, Xiaohui; Wang, Peng; Yang, Gui; Li, Xingwei; Zhao, Peng

2014-10-01

To investigate the new surgical pathway of endoscopic frontal sinus surgery for frontal sinus lesions through the upper-agger nasi approach. The computed tomography (CT) scans from 32 patients were collected and subjected to three-dimensional reconstruction by Mimics. The distance in sagittal planes from anterior ethmoid artery to midpoint of axilla and to skull base attachment at anterior middle turbinate was measured. The distance in coronal planes between the perpendicular plate of middle turbinate and the orbital lamina was also detected as well as the height of agger nasi. Three-dimensional structures of the frontal sinus and its surrounding cells was reconstructed by Sinuses Trachea I software. We integrated the CT scans and the above data for simulating surgical operation on cadaveric heads. (1) Skull base attachment at anterior middle turbinate located at the anterior or posterior of aperture of frontal sinus. (2) The mean distance between anterior ethmoid artery and midpoint of axilla was (22.23 ± 2.78) mm on the left side and (22.30 ± 2.80) mm on right. The mean distance between anterior ethmoid artery and skull base attachment at anterior middle turbinate was (15.31 ± 2.82) mm on left and (15.39 ± 3.53) mm on right. The distance between perpendicular plate of middle turbinate and orbital lamina was (7.61 ± 1.34) mm on left and (7.80 ± 1.40) mm on right side. The height of the agger nasi was (8.33 ± 2.14) mm on left and (8.00 ± 2.57) mm on right. There was no statistical difference in the above data between left and right side (P > 0.05). (3) The visible three-dimensional structure showed that skull base attachment at the anterior middle turbinate was closely adjoined the aperture of frontal sinus, the space between sub-outer side of the attachment and orbital lamina, above the agger nasi cell or the upper area of the agger nasi cell was solely cell structures. Endoscopic frontal sinus surgery for frontal sinus lesions through the upper-agger nasi approach was practicable to solitary frontal sinus lesions and to solve the complex frontal sinus or frontal recess lesions by flexible operation according to the feature of the lesions.

Functional Imaging of Human Vestibular Cortex Activity Elicited by Skull Tap and Auditory Tone Burst

NASA Technical Reports Server (NTRS)

Noohi, Fatemeh; Kinnaird, Catherine; Wood, Scott; Bloomberg, Jacob; Mulavara, Ajitkumar; Seidler, Rachael

2014-01-01

The aim of the current study was to characterize the brain activation in response to two modes of vestibular stimulation: skull tap and auditory tone burst. The auditory tone burst has been used in previous studies to elicit saccular Vestibular Evoked Myogenic Potentials (VEMP) (Colebatch & Halmagyi 1992; Colebatch et al. 1994). Some researchers have reported that airconducted skull tap elicits both saccular and utricle VEMPs, while being faster and less irritating for the subjects (Curthoys et al. 2009, Wackym et al., 2012). However, it is not clear whether the skull tap and auditory tone burst elicit the same pattern of cortical activity. Both forms of stimulation target the otolith response, which provides a measurement of vestibular function independent from semicircular canals. This is of high importance for studying the vestibular disorders related to otolith deficits. Previous imaging studies have documented activity in the anterior and posterior insula, superior temporal gyrus, inferior parietal lobule, pre and post central gyri, inferior frontal gyrus, and the anterior cingulate cortex in response to different modes of vestibular stimulation (Bottini et al., 1994; Dieterich et al., 2003; Emri et al., 2003; Schlindwein et al., 2008; Janzen et al., 2008). Here we hypothesized that the skull tap elicits the similar pattern of cortical activity as the auditory tone burst. Subjects put on a set of MR compatible skull tappers and headphones inside the 3T GE scanner, while lying in supine position, with eyes closed. All subjects received both forms of the stimulation, however, the order of stimulation with auditory tone burst and air-conducted skull tap was counterbalanced across subjects. Pneumatically powered skull tappers were placed bilaterally on the cheekbones. The vibration of the cheekbone was transmitted to the vestibular cortex, resulting in vestibular response (Halmagyi et al., 1995). Auditory tone bursts were also delivered for comparison. To validate our stimulation method, we measured the ocular VEMP outside of the scanner. This measurement showed that both skull tap and auditory tone burst elicited vestibular evoked activation, indicated by eye muscle response. Our preliminary analyses showed that the skull tap elicited activation in medial frontal gyrus, superior temporal gyrus, postcentral gyrus, transverse temporal gyrus, anterior cingulate, and putamen. The auditory tone bursts elicited activation in medial frontal gyrus, superior temporal gyrus, superior frontal gyrus, precentral gyrus, inferior and superior parietal lobules. In line with our hypothesis, skull taps elicited a pattern of cortical activity closely similar to one elicited by auditory tone bursts. Further analysis will determine the extent to which the skull taps can replace the auditory tone stimulation in clinical and basic science vestibular assessments.

Mice lacking the conserved transcription factor Grainyhead-like 3 (Grhl3) display increased apposition of the frontal and parietal bones during embryonic development.

PubMed

Goldie, Stephen J; Arhatari, Benedicta D; Anderson, Peter; Auden, Alana; Partridge, Darren D; Jane, Stephen M; Dworkin, Sebastian

2016-10-18

Increased apposition of the frontal and parietal bones of the skull during embryogenesis may be a risk factor for the subsequent development of premature skull fusion, or craniosynostosis. Human craniosynostosis is a prevalent, and often serious embryological and neonatal pathology. Other than known mutations in a small number of contributing genes, the aetiology of craniosynostosis is largely unknown. Therefore, the identification of novel genes which contribute to normal skull patterning, morphology and premature suture apposition is imperative, in order to fully understand the genetic regulation of cranial development. Using advanced imaging techniques and quantitative measurement, we show that genetic deletion of the highly-conserved transcription factor Grainyhead-like 3 (Grhl3) in mice (Grhl3 -/- ) leads to decreased skull size, aberrant skull morphology and premature apposition of the coronal sutures during embryogenesis. Furthermore, Grhl3 -/- mice also present with premature collagen deposition and osteoblast alignment at the sutures, and the physical interaction between the developing skull, and outermost covering of the brain (the dura mater), as well as the overlying dermis and subcutaneous tissue, appears compromised in embryos lacking Grhl3. Although Grhl3 -/- mice die at birth, we investigated skull morphology and size in adult animals lacking one Grhl3 allele (heterozygous; Grhl3 +/- ), which are viable and fertile. We found that these adult mice also present with a smaller cranial cavity, suggestive of post-natal haploinsufficiency in the context of cranial development. Our findings show that our Grhl3 mice present with increased apposition of the frontal and parietal bones, suggesting that Grhl3 may be involved in the developmental pathogenesis of craniosynostosis.

[Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

PubMed

Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

2016-04-01

We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.

Relative brain displacement and deformation during constrained mild frontal head impact.

PubMed

Feng, Y; Abney, T M; Okamoto, R J; Pless, R B; Genin, G M; Bayly, P V

2010-12-06

This study describes the measurement of fields of relative displacement between the brain and the skull in vivo by tagged magnetic resonance imaging and digital image analysis. Motion of the brain relative to the skull occurs during normal activity, but if the head undergoes high accelerations, the resulting large and rapid deformation of neuronal and axonal tissue can lead to long-term disability or death. Mathematical modelling and computer simulation of acceleration-induced traumatic brain injury promise to illuminate the mechanisms of axonal and neuronal pathology, but numerical studies require knowledge of boundary conditions at the brain-skull interface, material properties and experimental data for validation. The current study provides a dense set of displacement measurements in the human brain during mild frontal skull impact constrained to the sagittal plane. Although head motion is dominated by translation, these data show that the brain rotates relative to the skull. For these mild events, characterized by linear decelerations near 1.5g (g = 9.81 m s⁻²) and angular accelerations of 120-140 rad s⁻², relative brain-skull displacements of 2-3 mm are typical; regions of smaller displacements reflect the tethering effects of brain-skull connections. Strain fields exhibit significant areas with maximal principal strains of 5 per cent or greater. These displacement and strain fields illuminate the skull-brain boundary conditions, and can be used to validate simulations of brain biomechanics.

The classification of frontal sinus pneumatization patterns by CT-based volumetry.

PubMed

Yüksel Aslier, Nesibe Gül; Karabay, Nuri; Zeybek, Gülşah; Keskinoğlu, Pembe; Kiray, Amaç; Sütay, Semih; Ecevit, Mustafa Cenk

2016-10-01

We aimed to define the classification of frontal sinus pneumatization patterns according to three-dimensional volume measurements. Datasets of 148 sides of 74 dry skulls were generated by the computerized tomography-based volumetry to measure frontal sinus volumes. The cutoff points for frontal sinus hypoplasia and hyperplasia were tested by ROC curve analysis and the validity of the diagnostic points was measured. The overall frequencies were 4.1, 14.2, 37.2 and 44.5 % for frontal sinus aplasia, hypoplasia, medium size and hyperplasia, respectively. The aplasia was bilateral in all three skulls. Hypoplasia was seen 76 % at the right side and hyperplasia was seen 56 % at the left side. The cutoff points for diagnosing frontal sinus hypoplasia and hyperplasia were '1131.25 mm(3)' (95.2 % sensitivity and 100 % specificity) and '3328.50 mm(3)' (88 % sensitivity and 86 % specificity), respectively. The findings provided in the present study, which define frontal sinus pneumatization patterns by CT-based volumetry, proved that two opposite sides of the frontal sinuses are asymmetric and three-dimensional classification should be developed by CT-based volumetry, because two-dimensional evaluations lack depth measurement.

Development of a multi-exposure speckle imaging for mice brain imaging

NASA Astrophysics Data System (ADS)

Soleimanzad, Haleh; Gurden, Hirac; Pain, Frédéric

2017-02-01

In the last decade, Laser Speckle Contrast Imaging (LSCI) has been proposed and validated for imaging cerebral blood flow at the rodent brain surface in vivo. The technique relies on the calculation of the spatial speckle contrast, which is related to the velocity of scatterers (red blood cells). The implementation of the technique requires a partial craniotomy so that the brain tissues of interest can be illuminated with a laser diode. However, the studies of changes in the microcirculation during disease progression or treatment require longitudinal studies (i.e. imaging is done repeatedly over weeks or even months). Practically, the less invasive way to obtain such data is to image through the thinned skull without a craniotomy. However the presence of static scatterers (skull) will affect the speckle calculation and produce a bias in the estimation of the microcirculation changes. An extension to LSCI, termed Multi-Exposure Speckle Imaging (MESI) was proposed and validated a few years ago that address these limitations. It relies on a model of the speckle contrast as a function of the exposure time and the proportion of static scatterers. Here, we used MESI with the aim of repeatedly imaging the olfactory bulb of mice models of obesity. First, we have developed a MESI set up which was characterized on microfluidic flow phantoms with different flow-rates and channel diameters to simulate blood flow in animal model characteristics. Second, we show that MESI can discriminate flows in the presence of static scatterers and it can measure flow changes consistently. Finally we provide an in vivo validation of the technique in mice with and without a craniotomy.

Open Approaches to the Anterior Skull Base in Children: Review of the Literature.

PubMed

Wasserzug, Oshri; DeRowe, Ari; Ringel, Barak; Fishman, Gadi; Fliss, Dan M

2018-02-01

Introduction  Skull base lesions in children and adolescents are rare, and comprise only 5.6% of all skull base surgery. Anterior skull base lesions dominate, averaging slightly more than 50% of the cases. Until recently, surgery of the anterior skull base was dominated by open procedures and endoscopic skull base surgery was reserved for benign pathologies. Endoscopic skull base surgery is gradually gaining popularity. In spite of that, open skull base surgery is still considered the "gold standard" for the treatment of anterior skull base lesions, and it is the preferred approach in selected cases. Objective  This article reviews current concepts and open approaches to the anterior skull base in children in the era of endoscopic surgery. Materials and Methods  Comprehensive literature review. Results  Extensive intracranial-intradural invasion, extensive orbital invasion, encasement of the optic nerve or the internal carotid artery, lateral supraorbital dural involvement and involvement of the anterior table of the frontal sinus or lateral portion of the frontal sinus precludes endoscopic surgery, and mandates open skull base surgery. The open approaches which are used most frequently for surgical resection of anterior skull base tumors are the transfacial/transmaxillary, subcranial, and subfrontal approaches. Reconstruction of anterior skull base defects is discussed in a separate article in this supplement. Discussion  Although endoscopic skull base surgery in children is gaining popularity in developed countries, in many cases open surgery is still required. In addition, in developing countries, which accounts for more than 80% of the world's population, limited access to expensive equipment precludes the use of endoscopic surgery. Several open surgical approaches are still employed to resect anterior skull base lesions in the pediatric population. With this large armamentarium of surgical approaches, tailoring the most suitable approach to a specific lesion in regard to its nature, location, and extent is of utmost importance.

The return of Phineas Gage: clues about the brain from the skull of a famous patient.

PubMed

Damasio, H; Grabowski, T; Frank, R; Galaburda, A M; Damasio, A R

1994-05-20

When the landmark patient Phineas Gage died in 1861, no autopsy was performed, but his skull was later recovered. The brain lesion that caused the profound personality changes for which his case became famous has been presumed to have involved the left frontal region, but questions have been raised about the involvement of other regions and about the exact placement of the lesion within the vast frontal territory. Measurements from Gage's skull and modern neuroimaging techniques were used to reconstitute the accident and determine the probable location of the lesion. The damage involved both left and right prefrontal cortices in a pattern that, as confirmed by Gage's modern counterparts, causes a defect in rational decision making and the processing of emotion.

A novel ciliopathic skull defect arising from excess neural crest.

PubMed

Tabler, Jacqueline M; Rice, Christopher P; Liu, Karen J; Wallingford, John B

2016-09-01

The skull is essential for protecting the brain from damage, and birth defects involving disorganization of skull bones are common. However, the developmental trajectories and molecular etiologies by which many craniofacial phenotypes arise remain poorly understood. Here, we report a novel skull defect in ciliopathic Fuz mutant mice in which only a single bone pair encases the forebrain, instead of the usual paired frontal and parietal bones. Through genetic lineage analysis, we show that this defect stems from a massive expansion of the neural crest-derived frontal bone. This expansion occurs at the expense of the mesodermally-derived parietal bones, which are either severely reduced or absent. A similar, though less severe, phenotype was observed in Gli3 mutant mice, consistent with a role for Gli3 in cilia-mediated signaling. Excess crest has also been shown to drive defective palate morphogenesis in ciliopathic mice, and that defect is ameliorated by reduction of Fgf8 gene dosage. Strikingly, skull defects in Fuz mutant mice are also rescued by loss of one allele of fgf8, suggesting a potential route to therapy. In sum, this work is significant for revealing a novel skull defect with a previously un-described developmental etiology and for suggesting a common developmental origin for skull and palate defects in ciliopathies. Copyright © 2016 Elsevier Inc. All rights reserved.

Smart Stylet: The development and use of a bedside external ventricular drain image-guidance system

PubMed Central

Patil, Vaibhav; Gupta, Rajiv; Estépar, Raúl San José; Lacson, Ronilda; Cheung, Arnold; Wong, Judith M.; Popp, A. John; Golby, Alexandra; Ogilvy, Christopher; Vosburgh, Kirby G.

2015-01-01

Background Placement accuracy of ventriculostomy catheters is reported in a wide and variable range. Development of an efficient image-guidance system may improve physician performance and patient safety. Objective We evaluate the prototype of Smart Stylet, a new electromagnetic image-guidance system for use during bedside ventriculostomy. Methods Accuracy of the Smart Stylet system was assessed. System operators were evaluated for their ability to successfully target the ipsilateral frontal horn in a phantom model. Results Target registration error across 15 intracranial targets ranged from 1.3 – 4.6 mm (mean 3.1 mm). Using Smart Stylet guidance, a test operator successfully passed a ventriculostomy catheter to a shifted ipsilateral frontal horn 20/20 (100%) times from the frontal approach in a skull phantom. Without Smart Stylet guidance, the operator was successful 4/10 (40 %) from the right frontal approach and 6/10 (60 %) from the left frontal approach. In a separate experiment, resident operators were successful 2/4 (50%) when targeting the shifted ipsilateral frontal horn with Smart Stylet guidance and 0/4 (0 %) without image-guidance using a skull phantom. Conclusions Smart Stylet may improve the ability to successfully target the ventricles during frontal ventriculostomy. PMID:25662506

Use of the Draeger Apollo to Deliver Bilevel Positive Pressure Ventilation During Awake Frontal Craniotomy for a Patient with Severe Chronic Obstructive Pulmonary Disease.

PubMed

Lee, Susie So-Hyun; Berman, Mitchell F

2015-12-01

In this case report, we describe the use of the Draeger Apollo anesthesia machine to deliver bilevel positive airway pressure (BiPAP) to a patient with severe chronic obstructive pulmonary disease and a history of lung resection undergoing frontal craniotomy for the removal of a brain tumor under moderate to deep sedation. BiPAP in the perioperative period has been described for purposes of preoxygenation and postextubation recruitment. Although its utility as a mode of ventilation during moderate to deep sedation has been demonstrated, it has not come into widespread use. We describe the intraoperative use of pressure support mode on the anesthesia machine to deliver noninvasive positive pressure ventilation through a standard anesthesia mask. Given its ease of access and effectiveness, it is our belief that intraoperative BiPAP may reduce hypoxemia and/or hypercarbia in patients with chronic obstructive pulmonary disease and obstructive sleep apnea undergoing moderate to deep sedation.

Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note.

PubMed

Dolci, Ricardo Landini Lutaif; Todeschini, Alexandre Bossi; Santos, Américo Rubens Leite Dos; Lazarini, Paulo Roberto

2018-04-19

One of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. Describe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. Step by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. Both patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. This endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches. Copyright © 2018 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Giant convexity chondroma with meningeal attachment.

PubMed

Feierabend, Denise; Maksoud, Salah; Lawson McLean, Aaron; Koch, Arend; Kalff, Rolf; Walter, Jan

2018-06-01

Intracranial chondroma is a rare and benign tumor with usual onset in young adulthood. The skull base is the most common site of occurrence although, less often, the tumors can appear at the falx cerebri or at the dural convexity. The differentiation of these lesions from meningiomas through imaging is generally difficult. Clinical case presentation and review of the current literature. We report a case of a 25-year-old male patient with a giant convexity chondroma with meningeal attachment in the right frontal lobe that was detected after a first generalized seizure. Based on the putative diagnosis of meningioma, the tumor was completely resected via an osteoplastic parasagittal craniotomy. The postoperative MRI confirmed the complete tumor resection. Histopathological analysis revealed the presence of a chondroma. Intracranial chondromas are a rarity and their preoperative diagnosis based on neuroimaging is difficult. In young patients and those with skeletal disease, the differential diagnosis of a chondroma should be considered. In symptomatic patients, operative resection is sensible. In most cases total removal of the tumor is possible and leads to full recovery. When the finding is merely incidental in older patients, a watchful waiting approach is acceptable, given the benign and slow-growing nature of the lesion. Copyright © 2018 Elsevier B.V. All rights reserved.

Quantifying surgical access in eyebrow craniotomy with and without orbital bar removal: cadaver and surgical phantom studies.

PubMed

Zador, Zsolt; Coope, David J; Gnanalingham, Kanna; Lawton, Michael T

2014-04-01

Eyebrow craniotomy is a recently described minimally invasive approach for tackling primarily pathology of the anterior skull base. The removal of the orbital bar may further expand the surgical corridor of this exposure, but the extent of benefit is poorly quantified. We assessed the effect of orbital bar removal with regards to surgical access in the eyebrow craniotomy using classic morphometric measurements in cadaver heads. Using surgical phantoms and neuronavigation, we also measured the 'working volume', a new parameter for characterising the volume of surgical access in these approaches. Silicon injected cadaver heads (n = 5) were used for morphometric analysis of the eyebrow craniotomy with and without orbital bar removal. Working depths and 'working areas' of surgical access were measured as defined by key anatomical landmarks. The eyebrow craniotomy with or without orbital bar removal was also simulated using surgical phantoms (n = 3, 90-120 points per trial), calibrated against a frameless neuronavigation system. Working volume was derived from reference coordinates recorded along the anatomical borders of the eyebrow craniotomy using the "α-shape algorithm" in R statistics. In cadaver heads, eyebrow craniotomy with removal of the orbital bar reduced the working depth to the ipsilateral anterior clinoid process (42 ± 2 versus 33 ± 3 mm; p < 0.05), but the working areas as defined by deep neurovascular and bony landmarks was statistically unchanged (total working areas of 418 ± 80 cm(2) versus 334 ± 48 cm(2); p = 0.4). In surgical phantom studies, however, working-volume for the simulated eyebrow craniotomies was increased with orbital bar removal (16 ± 1 cm(3) versus 21 ± 1 cm(3); p < 0.01). In laboratory studies, orbital bar removal in eyebrow craniotomy provides a modest reduction in working depth and increase in the working volume. But this must be weighed up against the added morbidity of the procedure. Working volume, a newly developed parameter may provide a more meaningful endpoint for characterising the surgical access for different surgical approaches and it could be applied to other operative cases undertaken with frameless neuronavigation.

Effect of EEG Biofeedback on Convulsive Response to Monomethylhydrazine in the Rhesus Monkey

DTIC Science & Technology

1978-06-01

and sterile surgical procedures. A bilateral frontal- parietal craniotomy was performed and the dura opened to identify cortical anatomy. The location...conditioning of electroencephalographic activity while awake . Science 167: 1146-1148. Sterman, M. B., LoPresti, R. W. and Fairchild, M. D., June

[Metastasis of Hepatocellular Carcinoma to the Membrane of Chronic Subdural Hematomas:A Case Report].

PubMed

Oshita, Jumpei; Ohba, Shinji; Itou, Yoko; Yonezawa, Koki; Hosogai, Masahiro

2017-10-01

An 81-year-old man presented with gait disturbance. Two months previously, he suffered from hepatocellular carcinoma and transarterial chemoembolization was performed. A head computed tomography(CT)scan revealed bilateral chronic subdural hematomas. The patient's gait disturbance was improved after achievement of bilateral burr hole drainage. A head CT two months after treatment revealed no recurrence of the hematomas. However, head CT images obtained four months after treatment revealed an abnormal mass in the right parietal region attached to the internal surface of the skull. The mass was located in the same region from where the chronic subdural hematomas were previously removed via burr hole drainage, and was suspected to have originated from the dura mater. We performed craniotomy and total removal of the mass. The dura mater was intact, and macroscopically, the mass originated from the organized membrane of the chronic subdural hematoma. A pathological examination revealed metastasis of hepatocellular carcinoma to the membrane of the chronic subdural hematomas. Head magnetic resonance imaging(MRI)performed 39 days after craniotomy presented a new lesion in the left parietal region attached to the internal surface of the skull. The patient subsequently died 46 days post-operation. When examining chronic subdural hematomas in cancer patients, histological examination of the dura mater, hematoma, and membrane of the hematoma are important. The possibility of metastasis to the capsule of the hematoma should be considered.

Muscle Insertion Line as a Simple Landmark To Identify the Transverse Sinus When Neuronavigation Is Unavailable.

PubMed

Kivelev, Juri; Kivisaari, Riku; Niemelä, Mika; Hernesniemi, Juha

2016-10-01

Skull opening in occipital and suboccipital regions might be associated with risk of damage to the transverse venous sinus and the confluence of sinuses. We analyze the value of magnetic resonance (MR) imaging in localizing the venous sinuses in relation to the superior muscle insertion line (MIL) on the occipital bone. We retrospectively analyzed head MR images of 100 consecutive patients imaged for any reason from 1 January 2013. All MR images were interpreted by a radiologist (R.K.). The superior MIL was identified at the midline and on both midpupillar lines, which represent the most frequent sites of skin incision and craniotomy (median and lateral suboccipital craniotomy, respectively). Patients comprised 56 women (56%) and 44 men (44%). Their mean age was 54 (range 18-84) years. The muscles of the posterior skull were readily visible and clearly identified in both T1 and T2 images of all patients. Identification of the insertion zone and its relation to the venous structures was most readily made in the sagittal plane. We found that the upper muscle insertion line on occipital bone corresponds to the underlying venous sinus and can be used as a reliable anatomic landmark. We identified it in 100% of preoperative MR images of heads with an intact occiput. Copyright © 2016 Elsevier Inc. All rights reserved.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

PubMed Central

Kim, Jiha; Kim, Choonghyo; Ryu, Young-Joon

2016-01-01

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema. PMID:27226867

Awake craniotomy, electrophysiologic mapping, and tumor resection with high-field intraoperative MRI.

PubMed

Parney, Ian F; Goerss, Stephan J; McGee, Kiaran; Huston, John; Perkins, William J; Meyer, Frederic B

2010-05-01

Awake craniotomy and electrophysiologic mapping (EPM) is an established technique to facilitate the resection of near eloquent cortex. Intraoperative magnetic resonance imaging (iMRI) is increasingly used to aid in the resection of intracranial lesions. Standard draping protocols in high-field iMRI units make awake craniotomies challenging, and only two groups have previously reported combined EPM and high-field iMRI. We present an illustrative case describing a simple technique for combining awake craniotomy and EPM with high-field iMRI. A movable platter is used to transfer the patient from the operating table to a transport trolley and into the adjacent MRI and still maintaining the patient's surgical position. This system allows excess drapes to be removed, facilitating awake craniotomy. A 57-year-old right-handed man presented with new onset seizures. Magnetic resonance imaging demonstrated a large left temporal mass. The patient underwent an awake, left frontotemporal craniotomy. The EPM demonstrated a single critical area for speech in his inferior frontal gyrus. After an initial tumor debulking, the scalp flap was loosely approximated, the wound was covered with additional drapes, and the excess surrounding drapes were trimmed. An iMRI was obtained. The image-guidance system was re-registered and the patient was redraped. Additional resection was performed, allowing extensive removal of what proved to be an anaplastic astrocytoma. The patient tolerated this well without any new neurological deficits. Standard protocols for positioning and draping in high-field iMRI units make awake craniotomies problematic. This straightforward technique for combined awake EPM and iMRI may facilitate safe removal of large lesions in eloquent cortex. Copyright © 2010 Elsevier Inc. All rights reserved.

3D Printed, Customized Cranial Implant for Surgical Planning

NASA Astrophysics Data System (ADS)

Bogu, Venkata Phanindra; Ravi Kumar, Yennam; Asit Kumar, Khanra

2018-06-01

The main objective of the present work is to model cranial implant and printed in FDM machine (printer model used: mojo). Actually this is peculiar case and the skull has been damaged in frontal, parietal and temporal regions and a small portion of frontal region damaged away from saggital plane, complexity is to fill this frontal region with proper curvature. The Patient CT-data (Number of slices was 381 and thickness of each slice is 0.488 mm) was processed in mimics14.1 software, mimics file was sent to 3-matic software and calculated thickness of skull at different sections where cranial implant is needed then corrected the edges of cranial implant to overcome CSF (cerebrospinal fluid) leakage and proper fitting. Finally the implant average thickness is decided as 2.5 mm and printed in FDM machine with ABS plastic.

3D Printed, Customized Cranial Implant for Surgical Planning

NASA Astrophysics Data System (ADS)

Bogu, Venkata Phanindra; Ravi Kumar, Yennam; Asit Kumar, Khanra

2016-06-01

The main objective of the present work is to model cranial implant and printed in FDM machine (printer model used: mojo). Actually this is peculiar case and the skull has been damaged in frontal, parietal and temporal regions and a small portion of frontal region damaged away from saggital plane, complexity is to fill this frontal region with proper curvature. The Patient CT-data (Number of slices was 381 and thickness of each slice is 0.488 mm) was processed in mimics14.1 software, mimics file was sent to 3-matic software and calculated thickness of skull at different sections where cranial implant is needed then corrected the edges of cranial implant to overcome CSF (cerebrospinal fluid) leakage and proper fitting. Finally the implant average thickness is decided as 2.5 mm and printed in FDM machine with ABS plastic.

The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution

PubMed Central

Ormond, D. Ryan; Hadjipanayis, Costas G.

2013-01-01

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital “keyhole” approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration. PMID:23936644

Radio-anatomical analysis of the pericranial flap "money box approach" for ventral skull base reconstruction.

PubMed

Santamaría, Alfonso; Langdon, Cristóbal; López-Chacon, Mauricio; Cordero, Arturo; Enseñat, Joaquim; Carrau, Ricardo; Bernal-Sprekelsen, Manuel; Alobid, Isam

2017-11-01

To evaluate the versatility of the pericranial flap (PCF) to reconstruct the ventral skull base, using the frontal sinus as a gate for its passage into the sinonasal corridor "money box approach." Anatomic-radiological study and case series. Various approaches and their respective defects (cribriform, transtuberculum, clival, and craniovertebral junction) were completed in 10 injected specimens. The PCF was introduced into the nose through the uppermost portion of the frontal sinus (money box approach). Computed tomography (CT) scans (n = 50) were used to measure the dimensions of the PCF and the skull base defects. The vertical projection of the external ear canal was used as the reference point to standardize the incisions for the PCF. The surface area and maximum length of the PCF were 121.5 ± 19.4 cm 2 and 18.3 ± 1.3 cm, respectively. Using CT scans, we determined that to reconstruct defects secondary to transcribriform, transtuberculum, clival, and craniovertebral approaches, the PCF distal incision must be placed respectively at -3.7 ± 2.0 cm (angle -17.4 ± 8.5°), -0.2 ± 2.0 cm (angle -1.0 ± 9.3°), +5.5 ± 2.3 cm (angle +24.4 ± 9.7°), +8.4 ± 2.4 cm (angle +36.6 ± 11.5°), as related to the reference point. Skull base defects in our clinical cohort (n = 6) were completely reconstructed uneventfully with the PCF. The PCF renders enough surface area to reconstruct all possible defects in the ventral and median skull base. Using the uppermost frontal sinus as a gateway into the nose (money box approach) is feasible and simple. NA. Laryngoscope, 127:2482-2489, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

[A Case of Psychogenic Tremor during Awake Craniotomy].

PubMed

Kujirai, Kazumasa; Kamata, Kotoe; Uno, Toshihiro; Hamada, Keiko; Ozaki, Makoto

2016-01-01

A 31-year-old woman with a left frontal and parietal brain tumor underwent awake craniotomy. Propofol/remifentanil general anesthesia was induced. Following craniotomy, anesthetic administrations ceased. The level of consciousness was sufficient and she was not agitated. However, the patient complained of nausea 70 minutes into the awake phase. Considering the adverse effects of antiemetics and the upcoming surgical strategy, we did not give any medications. Nausea disappeared spontaneously while the operation was suspended. When surgical intervention extended to the left caudate nucleus, involuntary movement, classified as a tremor, with 5-6 Hz frequency, abruptly occurred on her left forearm. The patient showed emotional distress. Tremor appeared on her right forearm and subsequently spread to her lower extremities. Intravenous midazolam and fentanyl could not reduce her psychological stress. Since the tremor disturbed microscopic observation, general anesthesia was induced. Consequently, the tremor disappeared and did not recur. Based on the anatomical ground and the medication status, her involuntary movement was diagnosed as psychogenic tremor. Various factors can induce involuntary movements. In fact, intraoperative management of nausea and vomiting takes priority during awake craniotomy, but we should be reminded that some antiemetics potentially induce involuntary movement that could be caused by surgery around basal ganglia.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair.

PubMed

Grayson, Jessica W; Jeyarajan, Hari; Illing, Elisa A; Cho, Do-Yeon; Riley, Kristen O; Woodworth, Bradford A

2017-05-01

Management of frontal sinus trauma includes coronal or direct open approaches through skin incisions to either ablate or obliterate the frontal sinus for posterior table fractures and openly reduce/internally fixate fractured anterior tables. The objective of this prospective case-series study was to evaluate outcomes of frontal sinus anterior and posterior table trauma using endoscopic techniques. Prospective evaluation of patients undergoing surgery for frontal sinus fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of skull base defects, complications, and clinical follow-up. Forty-six patients (average age, 42 years) with frontal sinus fractures were treated using endoscopic techniques from 2008 to 2016. Mean follow-up was 26 (range, 0.5 to 79) months. Patients were treated primarily with a Draf IIb frontal sinusotomies. Draf III was used in 8 patients. Average fracture defect (length vs width) was 17.1 × 9.1 mm, and the average length involving the posterior table was 13.1 mm. Skull base defects were covered with either nasoseptal flaps or free tissue grafts. One individual required Draf IIb revision, but all sinuses were patent on final examination and all closed reductions of anterior table defects resulted in cosmetically acceptable outcomes. Frontal sinus trauma has traditionally been treated using open approaches. Our findings show that endoscopic management should become part of the management algorithm for frontal sinus trauma, which challenges current surgical dogma regarding mandatory open approaches. © 2017 ARS-AAOA, LLC.

The transnasal approach to the skull base. From sinus surgery to skull base surgery

PubMed Central

Wagenmann, Martin; Schipper, Jörg

2012-01-01

The indications for endonasal endoscopic approaches to diseases of the skull base and its adjacent structures have expanded considerably during the last decades. This is not only due to improved technical possibilities such as intraoperative navigation, the development of specialized instruments, and the compilation of anatomical studies from the endoscopic perspective but also related to the accumulating experience with endoscopic procedures of the skull base by multidisciplinary centers. Endoscopic endonasal operations permit new approaches to deeply seated lesions and are characterized by a reduced manipulation of neurovascular structures and brain parenchyma while at the same time providing improved visualization. They reduce the trauma caused by the approach, avoid skin incisions and minimize the surgical morbidity. Transnasal endoscopic procedures for the closure of small and large skull base defects have proven to be reliable and more successful than operations with craniotomies. The development of new local and regional vascularized flaps like the Hadad-flap have contributed to this. These reconstructive techniques are furthermore effectively utilized in tumor surgery in this region. This review delineates the classification of expanded endonasal approaches in detail. They provide access to lesions of the anterior, middle and partly also to the posterior cranial fossa. Successful management of these complex procedures requires a close interdisciplinary collaboration as well as continuous education and training of all team members. PMID:22558058

Olfactory Groove Meningiomas: Comparison of Extent of Frontal Lobe Changes After Lateral and Bifrontal Approaches.

PubMed

Nanda, Anil; Maiti, Tanmoy K; Bir, Shyamal C; Konar, Subhas K; Guthikonda, Bharat

2016-10-01

Olfactory groove meningiomas often are behaviorally silent. Numerous surgical approaches have been described in the literature for the successful removal of these meningiomas. Lateral (pterional/frontolateral) and anterior (bifrontal/fronto-orbito-basal) approaches with their various modifications remain the 2 major corridors in resecting them. In this study, we discuss our experience in microsurgical treatment of these tumors at our institution and assess the extent of frontal lobe damage after the resection of tumor. We reviewed the medical records of patients who underwent surgical excision of olfactory groove meningiomas from 1990 to 2014. To measure the extent of frontal lobe damage via lateral and anterior approaches, we measured the volume of porencephalic cave in the postoperative magnetic resonance imaging by using Brainlab software. The ratio of volume of porencephalic cave to tumor was measured between 2 sides and 2 approaches. Fifty-seven patients with olfactory groove meningiomas, who underwent 62 microsurgical resection procedures in 1990-2014 were included in the study (74% were more than 5 cm at presentation). Pterional and bifrontal craniotomies were the most commonly used approaches. At follow-up, the volume of porencephalic cave after lateral approach was significantly less in the side contralateral to craniotomy irrespective of tumor size. The difference between ratio of volume of porencephalic cave and initial tumor was significantly less after lateral approaches, when compared to anterior approaches. Lateral approaches (pterional/frontolateral) resulted in less frontal lobe change and better olfactory preservation in comparison to anterior approaches in present series. Published by Elsevier Inc.

Skull Base Anatomy.

PubMed

Patel, Chirag R; Fernandez-Miranda, Juan C; Wang, Wei-Hsin; Wang, Eric W

2016-02-01

The anatomy of the skull base is complex with multiple neurovascular structures in a small space. Understanding all of the intricate relationships begins with understanding the anatomy of the sphenoid bone. The cavernous sinus contains the carotid artery and some of its branches; cranial nerves III, IV, VI, and V1; and transmits venous blood from multiple sources. The anterior skull base extends to the frontal sinus and is important to understand for sinus surgery and sinonasal malignancies. The clivus protects the brainstem and posterior cranial fossa. A thorough appreciation of the anatomy of these various areas allows for endoscopic endonasal approaches to the skull base. Copyright © 2016 Elsevier Inc. All rights reserved.

A modified transcondylar screw to accommodate anatomical skull base variations.

PubMed

Ghaly, R F; Lissounov, A

2017-01-01

Occipitocervical instability may be attributed to congenital, bony/ligamentous abnormalities, trauma, neoplasm, degenerative bone disease, and failed atlantoaxial fixation. Indications for occipitocervical fixation include the prevention of disabling pain, cranial nerve dysfunction, paralysis, or even sudden death. The screw trajectory for the modified transcondylar screw (mTCS) is optimally planned utilizing a three-dimensional skull reconstructed image. The modified mTCS technique is helpful where there is a loss of bone, such as after prior suboccipital craniotomy and/or an inadequate occipital condyle. The new proposed technique is similar to the classical transcondylar screw placement but follows a deeper course along the bony lip of foramen magnum toward clivus from a dorsolateral approach. The modified mTCS technique allows for direct visualization and, therefore, helps to avoid damage to the hypoglossal nerve and lateral aspect of brain stem.

Relief of Headache by Cranioplasty After Skull Base Surgery

PubMed Central

Fetterman, Bruce L.; Lanman, Todd H.; House, John W.

1997-01-01

Headache after skull base surgery can cause profound morbidity in certain patients, resulting in significant impairment of their quality of life. Several methods to prevent postoperative headache have been described, including a modification of the skin/muscle incision replacing the craniotomy bone flap replacing the bone flap and filling in the residual defect with methyl methacrylate, using hydroxyapatite cement (HAC) to fill the craniectomy defect, and wiring hardened methyl methacrylate (MMA) into the defect. Ten patients with severe headache following craniectomy for a posterior fossa lesion underwent cranioplasty with MMA, which was placed exactly within the craniectomy defect and secured rigidly with miniplates and screws. The headache decreased in severity in all patients and resolved completely in 90%. Also, 78% of patients with dizziness improved. The procedure and its effect on headache and dizziness will be described. PMID:17171000

Patients cured of acromegaly do not experience improvement of their skull deformities.

PubMed

Rick, Jonathan W; Jahangiri, Arman; Flanigan, Patrick M; Aghi, Manish K

2017-04-01

Acromegaly is a rare disease that is associated with many co-morbidities. This condition also causes progressive deformity of the skull which includes frontal bossing and cranial thickening. Surgical and/or medical management can cure this condition in many patients, but it is not understood if patients cured of acromegaly experience regression of their skull deformities. We performed a retrospective analysis on patients treated at our dedicated pituitary center from 2009 to 2014. We looked at all MRI images taken during the treatment of these patients and recorded measurements on eight skull dimensions. We then analyzed these measurements for changes over time. 29 patients underwent curative treatment for acromegaly within our timeframe. The mean age for this population was 45.0 years old (range 19-70) and 55.2 % (n = 16) were female. All of these patients were treated with a transsphenoidal resection for a somatotropic pituitary adenoma. 9 (31.1%) of these patients required further medical therapy to be cured. We found statically significant variation in the coronal width of the sella turcica after therapy, which is likely attributable to changes from transsphenoidal surgery. None of the other dimensions had significant variation over time after cure. Patients cured of acromegaly should not expect natural regression of their skull deformities. Our study suggests that both frontal bossing and cranial thickening do not return to normal after cure.

Pediatric awake craniotomy and intra-operative stimulation mapping.

PubMed

Balogun, James A; Khan, Osaama H; Taylor, Michael; Dirks, Peter; Der, Tara; Carter Snead Iii, O; Weiss, Shelly; Ochi, Ayako; Drake, James; Rutka, James T

2014-11-01

The indications for operating on lesions in or near areas of cortical eloquence balance the benefit of resection with the risk of permanent neurological deficit. In adults, awake craniotomy has become a versatile tool in tumor, epilepsy and functional neurosurgery, permitting intra-operative stimulation mapping particularly for language, sensory and motor cortical pathways. This allows for maximal tumor resection with considerable reduction in the risk of post-operative speech and motor deficits. We report our experience of awake craniotomy and cortical stimulation for epilepsy and supratentorial tumors located in and around eloquent areas in a pediatric population (n=10, five females). The presenting symptom was mainly seizures and all children had normal neurological examinations. Neuroimaging showed lesions in the left opercular (n=4) and precentral or peri-sylvian regions (n=6). Three right-sided and seven left-sided awake craniotomies were performed. Two patients had a history of prior craniotomy. All patients had intra-operative mapping for either speech or motor or both using cortical stimulation. The surgical goal for tumor patients was gross total resection, while for all epilepsy procedures, focal cortical resections were completed without any difficulty. None of the patients had permanent post-operative neurologic deficits. The patient with an epileptic focus over the speech area in the left frontal lobe had a mild word finding difficulty post-operatively but this improved progressively. Follow-up ranged from 6 to 27 months. Pediatric awake craniotomy with intra-operative mapping is a precise, safe and reliable method allowing for resection of lesions in eloquent areas. Further validations on larger number of patients will be needed to verify the utility of this technique in the pediatric population. Copyright © 2014 Elsevier Ltd. All rights reserved.

Skull reconstruction after resection of bone tumors in a single surgical time by the association of the techniques of rapid prototyping and surgical navigation.

PubMed

Anchieta, M V M; Salles, F A; Cassaro, B D; Quaresma, M M; Santos, B F O

2016-10-01

Presentation of a new cranioplasty technique employing a combination of two technologies: rapid prototyping and surgical navigation. This technique allows the reconstruction of the skull cap after the resection of a bone tumor in a single surgical time. The neurosurgeon plans the craniotomy previously on the EximiusMed software, compatible with the Eximius Surgical Navigator, both from the company Artis Tecnologia (Brazil). The navigator imports the planning and guides the surgeon during the craniotomy. The simulation of the bone fault allows the virtual reconstruction of the skull cap and the production of a personalized modelling mold using the Magics-Materialise (Belgium)-software. The mold and a replica of the bone fault are made by rapid prototyping by the company Artis Tecnologia (Brazil) and shipped under sterile conditions to the surgical center. The PMMA prosthesis is produced during the surgical act with the help of a hand press. The total time necessary for the planning and production of the modelling mold is four days. The precision of the mold is submillimetric and accurately reproduces the virtual reconstruction of the prosthesis. The production of the prosthesis during surgery takes until twenty minutes depending on the type of PMMA used. The modelling mold avoids contraction and dissipates the heat generated by the material's exothermic reaction in the polymerization phase. The craniectomy is performed with precision over the drawing made with the help of the Eximius Surgical Navigator, according to the planned measurements. The replica of the bone fault serves to evaluate the adaptation of the prosthesis as a support for the perforations and the placement of screws and fixation plates, as per the surgeon's discretion. This technique allows the adequate oncologic treatment associated with a satisfactory aesthetic result, with precision, in a single surgical time, reducing time and costs.

Proof of Concept Study for the Design, Manufacturing, and Testing of a Patient-Specific Shape Memory Device for Treatment of Unicoronal Craniosynostosis.

PubMed

Borghi, Alessandro; Rodgers, Will; Schievano, Silvia; Ponniah, Allan; Jeelani, Owase; Dunaway, David

2018-01-01

Treatment of unicoronal craniosynostosis is a surgically challenging problem, due to the involvement of coronal suture and cranial base, with complex asymmetries of the calvarium and orbit. Several techniques for correction have been described, including surgical bony remodeling, early strip craniotomy with orthotic helmet remodeling and distraction. Current distraction devices provide unidirectional forces and have had very limited success. Nitinol is a shape memory alloy that can be programmed to the shape of a patient-specific anatomy by means of thermal treatment.In this work, a methodology to produce a nitinol patient-specific distractor is presented: computer tomography images of a 16-month-old patient with unicoronal craniosynostosis were processed to create a 3-dimensional model of his skull and define the ideal shape postsurgery. A mesh was produced from a nitinol sheet, formed to the ideal skull shape and heat treated to be malleable at room temperature. The mesh was afterward deformed to be attached to a rapid prototyped plastic skull, replica of the patient initial anatomy. The mesh/skull construct was placed in hot water to activate the mesh shape memory property: the deformed plastic skull was computed tomography scanned for comparison of its shape with the initial anatomy and with the desired shape, showing that the nitinol mesh had been able to distract the plastic skull to a shape close to the desired one.The shape-memory properties of nitinol allow for the design and production of patient-specific devices able to deliver complex, preprogrammable shape changes.

Benign fibrous histiocytoma of the fronto-temporo-parietal region: a case report and review of the literature

PubMed Central

Chen, Hongxu; Li, Pengcheng; Liu, Zhiyong; Xu, Jianguo; Hui, Xuhui

2015-01-01

Primary benign fibrous histiocytoma (BFH) at the skull is extremely rare. Here we report a case of a 22-year-old man presented with a 1-year history of progressive enlargement subcutaneous mass on the right side of the fronto-temporo-parietal region without symptoms. The tumor was radical resected through craniotomy and the bone defect was repaired by pre-plasticity titanium mesh. Histopathologic examination confirmed a benign fibrous histiocytoma, and no signs of tumor recurrence were detected at 3-year follow-up. PMID:26823894

Craniosynostosis repair - discharge

MedlinePlus

... a child's skull to grow together (fuse) too early. ... Craniectomy - child - discharge; Synostectomy - discharge; Strip craniectomy - discharge; Endoscopy-assisted craniectomy - discharge; Sagittal craniectomy - discharge; Frontal-orbital advancement - discharge; FOA - discharge

Coconut Model for Learning First Steps of Craniotomy Techniques and Cerebrospinal Fluid Leak Avoidance.

PubMed

Drummond-Braga, Bernardo; Peleja, Sebastião Berquó; Macedo, Guaracy; Drummond, Carlos Roberto S A; Costa, Pollyana H V; Garcia-Zapata, Marco T; Oliveira, Marcelo Magaldi

2016-12-01

Neurosurgery simulation has gained attention recently due to changes in the medical system. First-year neurosurgical residents in low-income countries usually perform their first craniotomy on a real subject. Development of high-fidelity, cheap, and largely available simulators is a challenge in residency training. An original model for the first steps of craniotomy with cerebrospinal fluid leak avoidance practice using a coconut is described. The coconut is a drupe from Cocos nucifera L. (coconut tree). The green coconut has 4 layers, and some similarity can be seen between these layers and the human skull. The materials used in the simulation are the same as those used in the operating room. The coconut is placed on the head holder support with the face up. The burr holes are made until endocarp is reached. The mesocarp is dissected, and the conductor is passed from one hole to the other with the Gigli saw. The hook handle for the wire saw is positioned, and the mesocarp and endocarp are cut. After sawing the 4 margins, mesocarp is detached from endocarp. Four burr holes are made from endocarp to endosperm. Careful dissection of the endosperm is done, avoiding liquid albumen leak. The Gigli saw is passed through the trephine holes. Hooks are placed, and the endocarp is cut. After cutting the 4 margins, it is dissected from the endosperm and removed. The main goal of the procedure is to remove the endocarp without fluid leakage. The coconut model for learning the first steps of craniotomy and cerebrospinal fluid leak avoidance has some limitations. It is more realistic while trying to remove the endocarp without damage to the endosperm. It is also cheap and can be widely used in low-income countries. However, the coconut does not have anatomic landmarks. The mesocarp makes the model less realistic because it has fibers that make the procedure more difficult and different from a real craniotomy. The model has a potential pedagogic neurosurgical application for freshman residents before they perform a real craniotomy for the first time. Further validity is necessary to confirm this hypothesis. Copyright © 2016 Elsevier Inc. All rights reserved.

Reliability of functional MR imaging with word-generation tasks for mapping Broca's area.

PubMed

Brannen, J H; Badie, B; Moritz, C H; Quigley, M; Meyerand, M E; Haughton, V M

2001-10-01

Functional MR (fMR) imaging of word generation has been used to map Broca's area in some patients selected for craniotomy. The purpose of this study was to measure the reliability, precision, and accuracy of word-generation tasks to identify Broca's area. The Brodmann areas activated during performance of word-generation tasks were tabulated in 34 consecutive patients referred for fMR imaging mapping of language areas. In patients performing two iterations of the letter word-generation tasks, test-retest reliability was quantified by using the concurrence ratio (CR), or the number of voxels activated by each iteration in proportion to the average number of voxels activated from both iterations of the task. Among patients who also underwent category or antonym word generation or both, the similarity of the activation from each task was assessed with the CR. In patients who underwent electrocortical stimulation (ECS) mapping of speech function during craniotomy while awake, the sites with speech function were compared with the locations of activation found during fMR imaging of word generation. In 31 of 34 patients, activation was identified in the inferior frontal gyri or middle frontal gyri or both in Brodmann areas 9, 44, 45, or 46, unilaterally or bilaterally, with one or more of the tasks. Activation was noted in the same gyri when the patient performed a second iteration of the letter word-generation task or second task. The CR for pixel precision in a single section averaged 49%. In patients who underwent craniotomy while awake, speech areas located with ECS coincided with areas of the brain activated during a word-generation task. fMR imaging with word-generation tasks produces technically satisfactory maps of Broca's area, which localize the area accurately and reliably.

Intact skull chronic windows for mesoscopic wide-field imaging in awake mice

PubMed Central

Silasi, Gergely; Xiao, Dongsheng; Vanni, Matthieu P.; Chen, Andrew C. N.; Murphy, Timothy H.

2016-01-01

Background Craniotomy-based window implants are commonly used for microscopic imaging, in head-fixed rodents, however their field of view is typically small and incompatible with mesoscopic functional mapping of cortex. New Method We describe a reproducible and simple procedure for chronic through-bone wide-field imaging in awake head-fixed mice providing stable optical access for chronic imaging over large areas of the cortex for months. Results The preparation is produced by applying clear-drying dental cement to the intact mouse skull, followed by a glass coverslip to create a partially transparent imaging surface. Surgery time takes about 30 minutes. A single set-screw provides a stable means of attachment for mesoscale assessment without obscuring the cortical field of view. Comparison with Existing Methods We demonstrate the utility of this method by showing seed-pixel functional connectivity maps generated from spontaneous cortical activity of GCAMP6 signals in both awake and anesthetized mice. Conclusions We propose that the intact skull preparation described here may be used for most longitudinal studies that do not require micron scale resolution and where cortical neural or vascular signals are recorded with intrinsic sensors. PMID:27102043

Assessment of frontal lobe sagging after endoscopic endonasal transcribriform resection of anterior skull base tumors: is rigid structural reconstruction of the cranial base defect necessary?

PubMed

Eloy, Jean Anderson; Shukla, Pratik A; Choudhry, Osamah J; Singh, Rahul; Liu, James K

2012-12-01

The endoscopic endonasal transcribriform approach (EETA) is a viable alternative option for resection of selected anterior skull base (ASB) tumors. However, this technique results in the creation of large cribriform defects. Some have reported the use of a rigid substitute for ASB reconstruction to prevent postoperative frontal lobe sagging. We evaluate the degree of frontal lobe sagging using our triple-layer technique [fascia lata, acellular dermal allograft, and pedicled nasoseptal flap (PNSF)] without the use of rigid structural reconstruction for large cribriform defects. Retrospective analysis. Nine patients underwent an EETA for resection of large ASB tumors from August 2010 to November 2011. The degree of frontal lobe displacement after EETA, defined as the ASB position, was calculated based on the most inferior position of the frontal lobe relative to the nasion-sellar line defined on preoperative and postoperative imaging. A positive value signified upward displacement, and a negative value represented inferior displacement of the frontal lobe. The average cribriform defect size was 9.3 cm(2) (range, 5.0-13.8 cm(2) ). The average distance of postoperative frontal lobe displacement was 0.2 mm (range, -3.9 to 2.9 mm) without any cases of significant brain sagging. The mean follow-up period was 10.1 months (range, 4-19 months). There were no postoperative CSF leaks. Rigid structural repair may not be necessary for ASB defect repair after endoscopic endonasal resection of the cribriform plate. Our technique for multilayer cranial base reconstruction appears to be satisfactory in preventing delayed frontal lobe sagging. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

Successful Insular Glioma Removal in a Deaf Signer Patient During an Awake Craniotomy Procedure.

PubMed

Metellus, Philippe; Boussen, Salah; Guye, Maxime; Trebuchon, Agnes

2017-02-01

Resection of tumors located within the insula of the dominant hemisphere represents a technical challenge because of the complex anatomy, including the surrounding vasculature, and the relationship to functional (motor and language) structures. We report here the case of a successful resection of a left insular glioma in a native deaf signer during an awake craniotomy. The patient, a congenitally deaf right-handed patient who is a native user of sign language, presented with a seizure 1 week before he was referred to our department. Magnetic resonance imaging revealed a left heterogeneous insular tumor enhanced after intravenous gadolinium infusion. Because of its deep and dominant hemisphere location, an awake craniotomy was decided. The patient was evaluated intraoperatively using object naming, text reading, and sign repetition tasks. An isolated inferior frontal gyrus site evoked repeated object naming errors. A transopercular parietal approach was performed and allowed the successful removal of the tumor under direct electric stimulation and electrocorticography. To our knowledge, this is the first report of successful removal of a left insular tumor without any functional sequelae in a native deaf signer using intraoperative direct cerebral stimulation during an awake craniotomy. The methodology used also provides the first evidence of the actual anatomo-functional organization of language in deaf signers. Copyright © 2016 Elsevier Inc. All rights reserved.

Chronic Subdural Hematoma Infected by Propionibacterium Acnes: A Case Report

PubMed Central

Yamamoto, Shusuke; Asahi, Takashi; Akioka, Naoki; Kashiwazaki, Daina; Kuwayama, Naoya; Kuroda, Satoshi

2015-01-01

We present a very rare case of a patient with an infected subdural hematoma due to Propionibacterium acnes. A 63-year-old male complained of dizziness and was admitted to our hospital. He had a history of left chronic subdural hematoma due to a traffic accident, which had been conservatively treated. Physical, neurological and laboratory examinations revealed no definite abnormality. Plain CT scan demonstrated a hypodense crescentic fluid collection over the surface of the left cerebral hemisphere. The patient was diagnosed with chronic subdural hematoma and underwent burr hole surgery three times and selective embolization of the middle meningeal artery, but the lesion easily recurred. Repeated culture examinations of white sedimentation detected P. acnes. Therefore, he underwent craniotomy surgery followed by intravenous administration of antibiotics. The infected subdural hematoma was covered with a thick, yellowish outer membrane, and the large volume of pus and hematoma was removed. However, the lesion recurred again and a low-density area developed in the left frontal lobe. Craniotomy surgery was performed a second time, and two Penrose drainages were put in both the epidural and subdural spaces. Subsequently, the lesions completely resolved and he was discharged without any neurological deficits. Infected subdural hematoma may be refractory to burr hole surgery or craniotomy alone, in which case aggressive treatment with craniotomy and continuous drainage should be indicated before the brain parenchyma suffers irreversible damage. PMID:25759659

Harvey Cushing's Approaches to Tumors in His Early Career: From the Skull Base to the Cranial Vault

PubMed Central

Pendleton, Courtney; Raza, Shaan M.; Gallia, Gary L.; Quiñones-Hinojosa, Alfredo

2011-01-01

In this report, we review Dr. Cushing's early surgical cases at the Johns Hopkins Hospital, revealing details of his early operative approaches to tumors of the skull base and cranial vault. Following Institutional Review Board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912. Participants included four adult patients and one child who underwent surgical resection of bony tumors of the skull base and the cranial vault. The main outcome measures were operative approach and condition recorded at the time of discharge. The indications for surgery included unspecified malignant tumor of the basal meninges and temporal bone, basal cell carcinoma, osteoma of the posterior skull base, and osteomas of the frontal and parietofrontal cranial vault. While Cushing's experience with selected skull base pathology has been previously reported, the breadth of his contributions to operative approaches to the skull base has been neglected. PMID:22470271

Minimally invasive surgery of the anterior skull base: transorbital approaches

PubMed Central

Gassner, Holger G.; Schwan, Franziska; Schebesch, Karl-Michael

2016-01-01

Minimally invasive approaches are becoming increasingly popular to access the anterior skull base. With interdisciplinary cooperation, in particular endonasal endoscopic approaches have seen an impressive expansion of indications over the past decades. The more recently described transorbital approaches represent minimally invasive alternatives with a differing spectrum of access corridors. The purpose of the present paper is to discuss transorbital approaches to the anterior skull base in the light of the current literature. The transorbital approaches allow excellent exposure of areas that are difficult to reach like the anterior and posterior wall of the frontal sinus; working angles may be more favorable and the paranasal sinus system can be preserved while exposing the skull base. Because of their minimal morbidity and the cosmetically excellent results, the transorbital approaches represent an important addition to established endonasal endoscopic and open approaches to the anterior skull base. Their execution requires an interdisciplinary team approach. PMID:27453759

Preferences and Utilities for Health States after Treatment of Olfactory Groove Meningioma: Endoscopic versus Open.

PubMed

Yao, Christopher M; Kahane, Alyssa; Monteiro, Eric; Gentili, Fred; Zadeh, Gelareh; de Almeida, John R

2017-08-01

Objectives  The purpose of this study is to report health utility scores for patients with olfactory groove meningiomas (OGM) treated with either the standard transcranial approach, or the expanded endonasal endoscopic approach. Design  The time trade-off technique was used to derive health utility scores. Setting  Healthy individuals without skull base tumors were surveyed. Main Outcome Measures  Participants reviewed and rated scenarios describing treatment (endoscopic, open, stereotactic radiation, watchful waiting), remission, recurrence, and complications associated with the management of OGMs. Results  There were 51 participants. The endoscopic approach was associated with higher utility scores compared with an open craniotomy approach (0.88 vs. 0.74; p  < 0.001) and watchful waiting (0.88 vs.0.74; p  = 0.002). If recurrence occurred, revision endoscopic resection continued to have a higher utility score compared with revision open craniotomy (0.68; p  = 0.008). On multivariate analysis, older individuals were more likely to opt for watchful waiting ( p  = 0.001), whereas participants from higher income brackets were more likely to rate stereotactic radiosurgery with higher utility scores ( p  = 0.017). Conclusion  The endoscopic approach was associated with higher utility scores than craniotomy for primary and revision cases. The present utilities can be used for future cost-utility analyses.

Aberrant growth of maxillary canine teeth in male babirusa (genus Babyrousa).

PubMed

Macdonald, Alastair A

2018-04-01

A worldwide survey of babirusa skulls curated in museum and private collections located 431 that were from adult males and had retained at least one maxillary canine tooth. Eighty-three of these skulls were identified as exhibiting aberrant maxillary canine tooth growth. Twenty-four of the skulls represented babirusa from Buru and the Sula Islands, and forty-five skulls represented babirusa from Sulawesi and the Togian Islands. The remaining series of fourteen babirusa skulls originally came from zoo animals. Fifteen skulls showed anomalous alveolar and tooth rotation in a median plane. Twenty-nine skulls had maxillary canine teeth that did not grow symmetrically towards the median plane of the cranium. Fourteen skulls showed evidence that the tips of one or both maxillary canine teeth had eroded the nasal bones. Twenty-one skulls had maxillary canine teeth that had eroded the frontal bones. The teeth of two skulls had eroded a parietal bone. One skull had two maxillary canines arising from an adjacent pair of alveoli on the left side of the cranium. Three skulls exhibited alveoli with no formed maxillary canine teeth in them. Analysis suggested that approximately 12% of the adult male babirusa in the wild experience erosion of the cranial bony tissues as a result of maxillary canine tooth growth. There was no skeletal evidence that maxillary canine teeth penetrate the eye. Crown Copyright © 2018. Published by Elsevier Masson SAS. All rights reserved.

The effect of the skull of low-birthweight neonates on applied potential tomography imaging of centralised resistivity changes.

PubMed

McArdle, F J; Brown, B H; Pearse, R G; Barber, D C

1988-01-01

An investigation is presented into the likely effects of the neonatal skull on impedance images produced by applied potential tomography (APT) by imaging impedance changes inside the skull of a human infant of occipito-frontal circumference 30 cm. Measurements have been made with the skull immersed in a tank of saline and electrodes fixed to the perimeter of the tank. Sensitivity measurements have been assessed for imaging a small target close to the centre of the skull as compared with images produced without the skull. The results obtained compare favourably with measurements on a more realistic model of the neonatal head constructed by filling the skull with agar jelly to leave only a thin exterior coating of jelly to simulate the scalp. These experiments suggest that in the central region of the head of a neonate, measured changes by the APT technique are about 44% of that expected from a homogeneous phantom, but that this might vary from 32% to 55% at different points in the image in a very complex manner.

Post-traumatic intracranial epidural Aspergillus fumigatus abscess.

PubMed

Letscher, V; Herbrecht, R; Gaudias, J; Taglang, G; Koenig, H; Dupuis, M G; Waller, J

1997-01-01

We report an intracranial epidural abscess caused by Aspergillus fumigatus in an immunocompetent patient. Infection occurred in a 20-year-old man 2 months after a frontal craniotomy following trauma. The abscess was encapsulated by a thickened dura and although the fungus did not invade the brain, frontal bone was infected and the patient presented with a subcutaneous frontal cellulitis. Initial management combined surgical drainage, resection of necrotic bone and liposomal amphotericin B (1 mg kg-1 per day). After 3 weeks of antifungal treatment a second evaluation surgery was performed. A clinically and radiologically unsuspected new abscess was found and evacuated. Treatment was completed with instillation into the cavity of amphotericin B at a concentration of 5 mg ml-1 and prolonged oral itraconazole (400-600 mg day-1). Treatment was successful and the patient is free of infection after 3 years.

Noninvasive Blood-Brain Barrier Opening in Live Mice

NASA Astrophysics Data System (ADS)

Choi, James J.; Pernot, Mathieu; Small, Scott; Konofagou, Elisa E.

2006-05-01

Most therapeutic agents cannot be delivered to the brain because of brain's natural defense: the Blood-Brain Barrier (BBB). It has recently been shown that Focused Ultrasound (FUS) can produce reversible and localized BBB opening in the brain when applied in the presence of ultrasound contrast agents post-craniotomy in rabbits [1]. However, a major limitation of ultrasound in the brain is the strong phase aberration and attenuation of the skull bone, and, as a result, no study of trans-cranial ultrasound-targeted drug treatment in the brain in vivo has been reported as of yet. In this study, the feasibility of BBB opening in the hippocampus of wildtype mice using FUS through the intact skull and skin was investigated. In order to investigate the effect of the skull, simulations of ultrasound wave propagation (1.5 MHz) through the skull using μCT data, and needle hydrophone measurements through an ex-vivo skull were made. The pressure field showed minimal attenuation (18% of the pressure amplitude) and a well-focused pattern through the left and right halves of the parietal bone. In experiments in vivo, the brains of four mice were sonicated through intact skull and skin. Ultrasound sonications (burst length: 20 ms; duty cycle: 20%; acoustic pressure range: 2.0 to 2.7 MPa) was applied 5 times for 30 s per shot with a 30 s delay between shots. Prior to sonication, ultrasound contrast agents (Optison; 10 μL) were injected intravenously. Contrast material enhanced high resolution MR Imaging (9.4 Tesla) was able to distinguish opening of large vessels in the region of the hippocampus. These results demonstrate the feasibility of locally opening the BBB in the mouse hippocampus using focused ultrasound through intact skull and skin. Future investigations will deal with optimization and reproducibility of the technique as well as application on Alzheimer's-model mice.

[A case of intracranial abscess caused by peri-odontogenic infection].

PubMed

Homma, Hiroomi; Takemura, Hideki; Yui, Takefumi; Ono, Tomohiro; Watanabe, Aya; Hayashi, Takeshi

2014-03-01

The authors report a case in which a 42-year-old woman developed an intracranial abscess in the temporal lobe as a result of a peri-odontogenic infection. A subdural abscess also developed in the middle cranial fossa, expanding directly from the base of the skull through the foramen ovale and the foramen spinosum. An operation involving a left-front temporal incision extending to the tragus was performed. Debridement and brain aspiration with drainage were carried out after the craniotomy via the same skin incision without operative complications. The patient left hospital 36 days after the operation without sequelae.

Piezosurgery for the repair of middle cranial fossa meningoencephaloceles.

PubMed

Acharya, Aanand N; Rajan, Gunesh P

2015-03-01

To describe the use of a piezosurgery medical device to perform a craniotomy and produce a split calvarial graft for the repair of middle cranial fossa meningoencephaloceles. Retrospective case review. Tertiary referral hospital. Ten consecutive patients undergoing middle cranial fossa approach for the repair of meningoencephaloceles. Therapeutic. Intraoperative and postoperative complications, success rate as defined by the ability to fashion a split calvarial graft that achieves complete closure of the tegmen defect. As a secondary outcome measure, evidence of integration of the split calvarial bone graft with the adjacent skull base was assessed. There were no intraoperative or postoperative complications. An appropriately sized calvarial bone graft was produced, and complete closure of the tegmen defect was achieved in all 10 cases. Computed tomography demonstrated evidence of integration of the bone graft in eight cases between 4 and 9 months after surgery. The piezosurgery medical device provides a safe and effective means by which the middle fossa craniotomy and split calvarial bone graft can be produced to repair defects of the middle fossa tegmen, with integration of the bone graft in the majority of cases.

Swallowing difficulties for cerebellar stroke may recover beyond three years.

PubMed

Périé, S; Wajeman, S; Vivant, R; St Guily, J L

1999-01-01

Swallowing disorders after stroke or skull base surgery can be life threatening. Although late recovery can occur, it remains poorly documented. We report a case of a 54-year-old woman with dysphagia resulting from a cerebellar stroke with hemorrhage that was evacuated through craniotomy. Swallowing difficulties were assessed by a videoendoscopic swallowing study. She presented with disruption of swallow initiation and impairment of the pharyngeal stage, resulting in hypopharyngeal stasis and penetration with aspiration. Supportive swallowing therapy was conducted with careful reeducation to assist initiation of the pharyngeal stage as well as development of compensatory postural technique. Initial improvement was very slow but became rapidly progressive from the 31st month after the stroke. By the 34th month, oral feeding was possible without aspiration. This case demonstrates that improvement in swallowing function can be expected even 3 years after stroke or skull base surgery. Determination of predictive factors for late functional recovery is of great importance and should be the focus of further investigation.

An unusual case of orbito-frontal rod fence stab injury with a good outcome.

PubMed

Miscusi, Massimo; Arangio, Paolo; De Martino, Luca; De-Giorgio, Fabio; Cascone, Piero; Raco, Antonino

2013-08-13

High-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features. A 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws. The patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact.The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists.

An unusual case of orbito-frontal rod fence stab injury with a good outcome

PubMed Central

2013-01-01

Background High-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features. Case presentation A 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws. Conclusion The patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact. The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists. PMID:23941677

Subcranial approach in the surgical treatment of anterior skull base trauma.

PubMed

Schaller, B

2005-04-01

Fractures of the anterior skull base, because of the region's anatomical relationships, are readily complicated by neurological damage to the brain or cranial nerves. This review highlights the use of a subcranial approach in the operative treatment of injuries of the anterior skull base and compares it to the more traditional neurosurgical transcranial approach. The extended anterior subcranial approach takes advantage of the specific features of injuries in this region and allows direct access to the central anterior cranial base in order to repair fractures, close CSF fistulae and relieve of optic nerve compression. It avoids extensive frontal lobe manipulation. The success of the approach in achieving the aims of surgery with low morbidity is reviewed.

Transcranial functional ultrasound imaging of the brain using microbubble-enhanced ultrasensitive Doppler

PubMed Central

Errico, Claudia; Osmanski, Bruno-Félix; Pezet, Sophie; Couture, Olivier; Lenkei, Zsolt; Tanter, Mickael

2016-01-01

Functional ultrasound (fUS) is a novel neuroimaging technique, based on high-sensitivity ultrafast Doppler imaging of cerebral blood volume, capable of measuring brain activation and connectivity in rodents with high spatiotemporal resolution (100 μm, 1 ms). However, the skull attenuates acoustic waves, so fUS in rats currently requires craniotomy or a thinned-skull window. Here we propose a non-invasive approach by enhancing the fUS signal with a contrast agent, inert gas microbubbles. Plane-wave illumination of the brain at high frame rate (500 Hz compounded sequence with three tilted plane waves, PRF = 1500Hz with a 128 element 15 MHz linear transducer), yields highly-resolved neurovascular maps. We compared fUS imaging performance through the intact skull bone (transcranial fUS) versus a thinned-skull window in the same animal. First, we show that the vascular network of the adult rat brain can be imaged transcranially only after a bolus intravenous injection of microbubbles, which leads to a 9 dB gain in the contrast-to-tissue ratio. Next, we demonstrate that functional increase in the blood volume of the primary sensory cortex after targeted electrical-evoked stimulations of the sciatic nerve is observable transcranially in presence of contrast agents, with high reproducibility (Pearson's coefficient ρ = 0.7 ± 0.1, p = 0.85). Our work demonstrates that the combination of ultrafast Doppler imaging and injection of contrast agent allows non-invasive functional brain imaging through the intact skull bone in rats. These results should ease non-invasive longitudinal studies in rodents and open a promising perspective for the adoption of highly resolved fUS approaches for the adult human brain. PMID:26416649

The Comprehensive AOCMF Classification: Skull Base and Cranial Vault Fractures – Level 2 and 3 Tutorial

PubMed Central

Ieva, Antonio Di; Audigé, Laurent; Kellman, Robert M.; Shumrick, Kevin A.; Ringl, Helmut; Prein, Joachim; Matula, Christian

2014-01-01

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial classification system with increasing level of complexity and details. The highest level 1 system distinguish four major anatomical units, including the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). This tutorial presents the level 2 and more detailed level 3 systems for the skull base and cranial vault units. The level 2 system describes fracture location outlining the topographic boundaries of the anatomic regions, considering in particular the endocranial and exocranial skull base surfaces. The endocranial skull base is divided into nine regions; a central skull base adjoining a left and right side are divided into the anterior, middle, and posterior skull base. The exocranial skull base surface and cranial vault are divided in regions defined by the names of the bones involved: frontal, parietal, temporal, sphenoid, and occipital bones. The level 3 system allows assessing fracture morphology described by the presence of fracture fragmentation, displacement, and bone loss. A documentation of associated intracranial diagnostic features is proposed. This tutorial is organized in a sequence of sections dealing with the description of the classification system with illustrations of the topographical skull base and cranial vault regions along with rules for fracture location and coding, a series of case examples with clinical imaging and a general discussion on the design of this classification. PMID:25489394

Blunt forehead trauma and optic canal involvement: finite element analysis of anterior skull base and orbit on causes of vision impairment.

PubMed

Huempfner-Hierl, Heike; Bohne, Alexander; Wollny, Gert; Sterker, Ina; Hierl, Thomas

2015-10-01

Clinical studies report on vision impairment after blunt frontal head trauma. A possible cause is damage to the optic nerve bundle within the optic canal due to microfractures of the anterior skull base leading to indirect traumatic optic neuropathy. A finite element study simulating impact forces on the paramedian forehead in different grades was initiated. The set-up consisted of a high-resolution skull model with about 740 000 elements, a blunt impactor and was solved in a transient time-dependent simulation. Individual bone material parameters were calculated for each volume element to increase realism. Results showed stress propagation from the frontal impact towards the optic foramen and the chiasm even at low-force fist-like impacts. Higher impacts produced stress patterns corresponding to typical fracture patterns of the anterior skull base including the optic canal. Transient simulation discerned two stress peaks equalling oscillation. It can be concluded that even comparatively low stresses and oscillation in the optic foramen may cause micro damage undiscerned by CT or MRI explaining consecutive vision loss. Higher impacts lead to typical comminuted fractures, which may affect the integrity of the optic canal. Finite element simulation can be effectively used in studying head trauma and its clinical consequences. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Transnasal endoscopic management of frontal sinus mucopyocele with orbital and frontal lobe displacement as minimally invasive surgery.

PubMed

Bozza, F; Nisii, A; Parziale, G; Sherkat, S; Del Deo, V; Rizzo, A

2010-03-01

An obstructive condition of paranasal sinus secondary to surgery, trauma, flogosis or neoplasms could become a predisposing state to the occurrence of mucocele. Frontal sinus mucoceles, which can turn into mucopyoceles due to bacterial super-infections, may invade the orbit, erode the skull base and displace respectively the ocular bulb and the frontal lobe. The surgical treatment of this disease ranges from mini-invasive approaches, such as the transnasal endoscopic marsupialization, to a more aggressive surgery such as osteoplasty through coronal flap and frontal sinus exclusion by fat tissue. From 2005 to 2007, we treated with transnasal endoscopic surgery 10 patients, affected by frontal sinus mucopyoceles displacing both the ocular bulb and the frontal lobe. In the present study, we report the clinical and diagnostic features of this series, the treatment modalities and the achieved results and confirm the effectiveness of the mini-invasive transnasal endoscopic technique in the treatment of the frontal sinus mucopyocele.

Comparison of endoscopic endonasal and bifrontal craniotomy approaches for olfactory groove meningiomas: A matched pair analysis of outcomes and frontal lobe changes on MRI.

PubMed

de Almeida, John R; Carvalho, Felipe; Vaz Guimaraes Filho, Francisco; Kiehl, Tim-Rasmus; Koutourousiou, Maria; Su, Shirley; Vescan, Allan D; Witterick, Ian J; Zadeh, Gelareh; Wang, Eric W; Fernandez-Miranda, Juan C; Gardner, Paul A; Gentili, Fred; Snyderman, Carl H

2015-11-01

We compare the outcomes and postoperative MRI changes of endoscopic endonasal (EEA) and bifrontal craniotomy (BFC) approaches for olfactory groove meningiomas (OGM). All patients who underwent either BFC or EEA for OGM were eligible. Matched pairs were created by matching tumor volumes of an EEA patient with a BFC patient, and matching the timing of the postoperative scans. The tumor dimensions, peritumoral edema, resectability issues, and frontal lobe changes were recorded based on preoperative and postoperative MRI. Postoperative fluid-attenuated inversion recovery (FLAIR) hyperintensity and residual cystic cavity (porencephalic cave) volume were compared using univariable and multivariable analyses. From a total of 70 patients (46 EEA, 24 BFC), 10 matched pairs (20 patients) were created. Three patients (30%) in the EEA group and two (20%) in the BFC had postoperative cerebrospinal fluid leaks (p=0.61). Gross total resections were achieved in seven (70%) of the EEA group and nine (90%) of the BFC group (p=0.26), and one patient from each group developed a recurrence. On postoperative MRI, there was no significant difference in FLAIR signal volumes between EEA and BFC approaches (6.9 versus 13.3 cm(3); p=0.17) or in porencephalic cave volumes (1.7 versus 5.0 cm(3); p=0.11) in univariable analysis. However, in a multivariable analysis, EEA was associated with less postoperative FLAIR change (p=0.02) after adjusting for the volume of preoperative edema. This study provides preliminary evidence that EEA is associated with quantifiable improvements in postoperative frontal lobe imaging. Copyright © 2015 Elsevier Ltd. All rights reserved.

Penetrating skull fracture by a wooden object: Management dilemmas and literature review

PubMed Central

Arifin, Muhammad Zafrullah; Gill, Arwinder Singh; Faried, Ahmad

2012-01-01

Most penetrating skull injuries are caused by gun shot wounds or missiles. The compound depressed skull fracture represents an acute neurosurgical emergency. Management and diagnosis of such cases have been described, but its occurence following a fall onto a piece of wood is quite unusual. A 75-year-old female fell onto a piece of wood that penetrated her skull on the left frontal region and was treated in our department. The patient had no neurological deficits during presentation. She was managed surgically and removal of the wooden object was performed to prevent early or late infection complications. Wooden foreign bodies often pose a different set of challenges as far as penetrating injuries to the brain are concerned. Radiological difficulties and increased rates of infection due to its porous nature make these types of injuries particularly interesting. Their early diagnosis and appropriate treatment can minimize the risk of complications. PMID:23293668

From Mystics to Modern Times: A History of Craniotomy & Religion.

PubMed

Newman, W Christopher; Chivukula, Srinivas; Grandhi, Ramesh

2016-08-01

Neurosurgical treatment of diseases dates back to prehistoric times and the trephination of skulls for various maladies. Throughout the evolution of trephination, surgery and religion have been intertwined to varying degrees, a relationship that has caused both stagnation and progress. From its mystical origins in prehistoric times to its scientific progress in ancient Egypt and its resurgence as a well-validated surgical technique in modern times, trephination has been a reflection of the cultural and religious times. Herein we present a brief history of trephination as it relates religion, culture, and the evolution of neurosurgery. Copyright © 2016 Elsevier Inc. All rights reserved.

[Anatomical and computed tomographic analysis of the interaction between uncinate process and agger nasi cells].

PubMed

Zhang, Luo; Han, De-min; Ge, Wen-tong; Zhou, Bing; Xian, Jun-fang; Liu, Zhong-yan; Wang, Kui-ji; He, Fei

2005-12-01

To investigate the anatomical interaction between uncinate process and agger nasi cell to better understand the anatomy of the frontal sinus drainage pathway by endoscopy, spiral computed tomography (CT) and sectioning. Twenty-one skeletal skulls (forty-two sides) and one cadaver head (two sides) were studied by spiral CT together with endoscopy and collodion embedded thin sectioning at coronal plane. The sections with the thickness of 100 microm were stained with hemotoxylin and eosin. Under endoscopy, a leaflet of bone to the middle turbinate, which is given off by uncinate process, forms the anterior insertion of the middle turbinate onto the lateral nasal wall. The middle portion of the uncinate process attached to the frontal process of the maxilla in all of the skeletal nasal cavities, as well as the lacrimal bone in 78.6% of the skeletal nasal cavities. On CT scans, the agger nasi cell is present in 90.5% of the skeletal nasal cavities. While the lateral wall of the agger nasi cell is formed by lacrimal bone, the medial wall of the agger nasi cell is formed by uncinate process. And the anterior wall is formed by the frontal process of the maxilla. The superior portion of the uncinate process forms the medial, posterior and top wall of the agger nasi cells. The superior portion of the uncinate extends into the frontal recess and may insert into lamina papyracea (33.3%), skull base (9.5%), middle turbinate, combination of these (57.2%). The agger nasi cell is the key that unlocks the frontal recess.

Clinical outcomes from maximum-safe resection of primary and metastatic brain tumors using awake craniotomy.

PubMed

Groshev, Anastasia; Padalia, Devang; Patel, Sephalie; Garcia-Getting, Rosemarie; Sahebjam, Solmaz; Forsyth, Peter A; Vrionis, Frank D; Etame, Arnold B

2017-06-01

To retrospectively analyze outcomes in patients undergoing awake craniotomies for tumor resection at our institution in terms of extent of resection, functional preservation and length of hospital stay. All cases of adults undergoing awake-craniotomy from September 2012-February 2015 were retrospectively reviewed based on an IRB approved protocol. Information regarding patient age, sex, cancer type, procedure type, location, hospital stay, extent of resection, and postoperative complications was extracted. 76 patient charts were analyzed. Resected cancer types included metastasis to the brain (41%), glioblastoma (34%), WHO grade III anaplastic astrocytoma (18%), WHO grade II glioma (4%), WHO grade I glioma (1%), and meningioma (1%). Over a half of procedures were performed in the frontal lobes, followed by temporal, and occipital locations. The most common indication was for motor cortex and primary somatosensory area lesions followed by speech. Extent of resection was gross total for 59% patients, near-gross total for 34%, and subtotal for 7%. Average hospital stay for the cohort was 1.7days with 75% of patients staying at the hospital for only 24h or less post surgery. In the postoperative period, 67% of patients experienced improvement in neurological status, 21% of patients experienced no change, 7% experienced transient neurological deficits, which resolved within two months post op, 1% experienced transient speech deficit, and 3% experienced permanent weakness. In a consecutive series of 76 patients undergoing maximum-safe resection for primary and metastatic brain tumors, awake-craniotomy was associated with a short hospital stay and low postoperative complications rate. Copyright © 2017 Elsevier B.V. All rights reserved.

Comparative finite element analysis of skull mechanical properties following parietal bone graft harvesting in adults.

PubMed

Haen, Pierre; Dubois, Guillaume; Goudot, Patrick; Schouman, Thomas

2018-02-01

Parietal bone grafts are commonly used in cranio-maxillo-facial surgery. Both the outer and the internal layer of the calvarium can be harvested. The bone defect created by this harvesting may induce significant weakening of the skull that has not been extensively evaluated. Our aim was to evaluate the consequences of parietal bone graft harvesting on mechanical properties of the skull using a finite element analysis. Finite elements models of the skull of 3 adult patients were created from CT scans. Parietal external and internal layer harvest models were created. Frontal, lateral, and parietal loading were modeled and von Mises stress distributions were compared. The maximal von Mises stress was higher for models of bone harvesting, both on the whole skull and at the harvested site. Maximal von Mises stress was even higher for models with internal layer defect. Harvesting parietal bone modifies the skull's mechanical strength and can increase the risk of skull fracture, mainly on the harvested site. Outer layer parietal graft harvesting is indicated. Graft harvesting located in the upper part of the parietal bone, close to the sagittal suture and with smooth internal edges and corners should limit the risk of fracture. Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Transversal craniofacial growth evaluated on children dry skulls using V2 and V 3 canal openings as references.

PubMed

Harnet, J C; Lombardi, T; Manière-Ezvan, A; Chamorey, E; Kahn, J L

2013-11-01

The aim of this study was to investigate the transversal relationships between two cephalometric landmarks and lines on the face using ovale, rotundum, greater palatine and infra-orbital foramina as references. Thirty-four children dry skulls, 19 males and 15 females aged 0-6 years, were examined by computed tomography scanning by using constructed tomographic axial and frontal planes. The cephalometric transversal dimensions of the face skull were measured between the right and left landmarks from the orbital lateral wall and from the zygomatic arch. The cephalometric transversal dimensions of the base skull were measured between the right and left ovale, rotundum, greater palatine and infra-orbital foramina. Statistical analysis using partial correlations, regardless of the age, showed strong relationships (p < 0.05) among transversal measurements with nerve canal openings and transversal distances of skull face. We showed that the cranial base transversal growth was very strongly related to facial transversal growth from the postnatal period up to 6 years of age.

Lateral Transorbital Endoscopic Access to the Hippocampus, Amygdala, and Entorhinal Cortex: Initial Clinical Experience.

PubMed

Chen, H Isaac; Bohman, Leif-Erik; Emery, Lyndsey; Martinez-Lage, Maria; Richardson, Andrew G; Davis, Kathryn A; Pollard, John R; Litt, Brian; Gausas, Roberta E; Lucas, Timothy H

2015-01-01

Transorbital approaches traditionally have focused on skull base and cavernous sinus lesions medial to the globe. Lateral orbital approaches to the temporal lobe have not been widely explored despite several theoretical advantages compared to open craniotomy. Recently, we demonstrated the feasibility of the lateral transorbital technique in cadaveric specimens with endoscopic visualization. We describe our initial clinical experience with the endoscope-assisted lateral transorbital approach to lesions in the temporal lobe. Two patients with mesial temporal lobe pathology presenting with seizures underwent surgery. The use of a transpalpebral or Stallard-Wright eyebrow incision enabled access to the intraorbital compartment, and a lateral orbital wall 'keyhole' opening permitted visualization of the anterior temporal pole. This approach afforded adequate access to the surgical target and surrounding structures and was well tolerated by the patients. To the best of our knowledge, this report constitutes the first case series describing the endoscope-assisted lateral transorbital approach to the temporal lobe. We discuss the limits of exposure, the nuances of opening and closing, and comparisons to open craniotomy. Further prospective investigation of this approach is warranted for comparison to traditional approaches to the mesial temporal lobe. © 2015 S. Karger AG, Basel.

Feasibility of Telementoring for Microneurosurgical Procedures Using a Microscope: A Proof-of-Concept Study.

PubMed

Ladd, Bryan M; Tackla, Ryan D; Gupte, Akshay; Darrow, David; Sorenson, Jeffery; Zuccarello, Mario; Grande, Andrew W

2017-03-01

Our pilot study evaluated the effectiveness of our telementoring-telescripting model to facilitate seamless communication between surgeons while the operating surgeon is using a microscope. As a first proof of concept, 4 students identified 20 anatomic landmarks on a dry human skull with or without telementoring guidance. To assess the ability to communicate operative information, a senior neurosurgery resident evaluated the student's ability and timing to complete a stepwise craniotomy on a cadaveric head, with and without telementoring guidance; a second portion included exposure of the anterior circulation. The mentor was able to annotate directly onto the operator's visual field, which was visible to the operator without looking away from the binocular view. The students showed that they were familiar with half (50% ± 10%) of the structures for identification and none was familiar with the steps to complete a craniotomy before using our system. With the guidance of a remote surgeon projected into the visual field of the microscope, the students were able to correctly identify 100% of the structures and complete a craniotomy. Our system also proved effective in guiding a more experienced neurosurgery resident through complex operative steps associated with exposure of the anterior circulation. Our pilot study showed a platform feasible in providing effective operative direction to inexperienced operators while operating using a microscope. A remote mentor was able to view the visual field of the microscope, annotate on the visual stream, and have the annotated stream appear in the binocular view for the operating mentee. Copyright © 2016 Elsevier Inc. All rights reserved.

Craniofacial resection and its role in the management of sinonasal malignancies.

PubMed

Taghi, Ali; Ali, Ahmed; Clarke, Peter

2012-09-01

Sinonasal malignancy is rare, and its presentation is commonly late. There is a wide variety of pathologies with varying natural histories and survival rates. Anatomy of the skull base is extremely complex and tumors are closely related to orbits, frontal lobes and cavernous sinus. Anatomical detail and the late presentation render surgical management a challenging task. A thorough understanding of anatomy and pathology combined with modern neuroimaging and reliable reconstruction within a multidisciplinary team is imperative to carry out skull base surgery effectively. While endoscopic approaches are gaining credibility, clearly, it will be some time before meaningful comparisons with craniofacial resection can be made. Until then, craniofacial resection will remain the gold standard for managing the sinonasal malignancies of the anterior skull base, as it has proved to be safe and effective.

The effect of rigid fixation on growth of the neurocranium.

PubMed

Wong, L; Dufresne, C R; Richtsmeier, J T; Manson, P N

1991-09-01

The effects on skull growth of plating the coronal suture and frontal bone were studied in New Zealand White rabbits. Three-dimensional coordinate landmarks were digitized and analyzed to determine the differences in form between operated and unoperated animals using Euclidian distance matrix analysis. This method compares sets of interlandmark distances in three dimensions and was used to demonstrate changes induced by plating. We interpret these changes in morphology to be the result of differences in growth between the operated and unoperated groups. Periosteal elevation alone (n = 6) resulted in a minimal local growth increase. Coronal suture plating (n = 8) resulted in local growth restriction with contralateral and adjacent size increases. Frontal bone plating (n = 6) without crossing a suture line also resulted in local growth restriction and adjacent bone size increases. The timing of intervention in relation to the completion of bone growth may explain the magnitude of clinically apparent effects. Changes in bones adjacent to those directly manipulated may be an attempt to maintain a normal skull volume.

Frontal dermoid cyst coexisting with suprasellar craniopharyngioma: a spectrum of ectodermally derived epithelial-lined cystic lesions?

PubMed

Abou-Al-Shaar, Hussam; Abd-El-Barr, Muhammad M; Zaidi, Hasan A; Russell-Goldman, Eleanor; Folkerth, Rebecca D; Laws, Edward R; Chiocca, E Antonio

2016-12-01

There is a wide group of lesions that may exist in the sellar and suprasellar regions. Embryologically, there is varying evidence that many of these entities may in fact represent a continuum of pathology deriving from a common ectodermal origin. The authors report a case of a concomitant suprasellar craniopharyngioma invading the third ventricle with a concurrent frontal lobe cystic dermoid tumor. A 21-year-old man presented to the authors' service with a 3-day history of worsening headache, nausea, vomiting, and blurry vision. Magnetic resonance imaging depicted a right frontal lobe lesion associated with a separate suprasellar cystic lesion invading the third ventricle. The patient underwent a right pterional craniotomy for resection of both lesions. Gross-total resection of the right frontal lesion was achieved, and subtotal resection of the suprasellar lesion was accomplished with some residual tumor adherent to the walls of the third ventricle. Histopathological examination of the resected right frontal lesion documented a diagnosis of dermoid cyst and, for the suprasellar lesion, a diagnosis of adamantinomatous craniopharyngioma. The occurrence of craniopharyngioma with dermoid cyst has not been reported in the literature before. Such an association might indeed suggest the previously reported hypothesis that these lesions represent a spectrum of ectodermally derived epithelial-lined cystic lesions.

Fronto-ethmoidal Osteoma with Secondary Intradural Mucocele Extension causing Frontal Lobe Syndrome and Pneumocephalus: Case Report and Review of the Literature.

PubMed

Maria, Licci; Christian, Zweifel; Jürgen, Hench; Raphael, Guzman; Jehuda, Soleman

2018-04-18

Paranasal sinus osteoma is a common, asymptomatic, histologically benign, and slow-growing tumor. However, it can give rise to secondary pathologies such as a mucocele in about 50% of the cases. Rarely, intracranial and orbital extension is present leading to rhinoliquorrhea, pneumocephalus, or neurological and visual impairment, which might be potentially life-threatening. A 49-year old man presented with an acute frontal lobe syndrome and rhinoliquorrhea. Cranial magnetic resonance tomography showed a suspected fronto-ethmoidal osteoma with a mucocele expanding intradurally, into the left frontal lobe. It was accompanied by pneumocephalus and showed communication with the left lateral ventricle. Through a bifrontal craniotomy in toto resection of the fronto-ethmoidal bony tumor and the intradural mucocele was performed, while thereafter the frontal sinus was cranialized using a pedunculated periosteal flap. Postoperative recovery was uneventful with complete resolvement of the tension pneumocephalus and the rhinoliquorrhea, and led to an improvement of the frontal lobe syndrome. We present a rare case of pneumocephalus caused by a fronto-ethmoidal osteoma associated with an intradural mucocele. A review of the literature, focusing on the surgical strategies in such cases, is provided. Copyright © 2018 Elsevier Inc. All rights reserved.

Rhinogenic intracranial complication with postoperative frontal sinus pyocele and inverted papilloma in the nasal cavity: A case report and literature review

PubMed Central

Kawada, Michitsugu; Yokoi, Hidenori; Maruyama, Keisuke; Matsumoto, Yuma; Yamanaka, Hidetaka; Ikeda, Tetsuya; Shiokawa, Yoshiaki; Saito, Koichiro

2016-01-01

We report a patient who had rhinogenic intracranial complication with postoperative frontal sinus pyocele and inverted papilloma in the nasal cavity. A 72-year-old woman had undergone surgery for frontal sinusitis via external incision at another hospital 13 years previously. Left-sided hemiparesis appeared in the patient and gradually worsened. Five days later, she exhibited disorientation, abnormal behavior, poor articulation, and difficulty in standing. Therefore, she was taken to the neurosurgery department by ambulance. An extensive frontal sinus pyocele was suspected, and a cerebral abscess and edema of the frontal lobe were observed on magnetic resonance imaging. After antibiotics, steroid and glycerol were administered for a few weeks; disorientation and left hemiparesis improved. Next, craniotomy for complete removal of the brain abscess by neurosurgeons and endoscopic endonasal surgery by otolaryngologists were carried out at the same surgery. From the analysis of the pathological mucosa sample taken from the right ethomoidal sinus during surgery, an inverted papilloma was diagnosed. The patient completely recovered and is currently receiving follow-up examination. Regarding rhinogenic intracranial complications, ascertaining clinical condition in order to determine the need for either immediate radical surgery, or for curative surgery after waiting for improvement of the overall body condition by conservative management, is still needed. PMID:27489711

Expanded Endoscopic Endonasal Approaches to Skull Base Meningiomas

PubMed Central

Prosser, J. Drew; Vender, John R.; Alleyne, Cargill H.; Solares, C. Arturo

2012-01-01

Anterior cranial base meningiomas have traditionally been addressed via frontal or frontolateral approaches. However, with the advances in endoscopic endonasal treatment of pituitary lesions, the transphenoidal approach is being expanded to address lesions of the petrous ridge, anterior clinoid, clivus, sella, parasellar region, tuberculum, planum, olfactory groove, and crista galli regions. The expanded endoscopic endonasal approach (EEEA) has the advantage of limiting brain retraction and resultant brain edema, as well as minimizing manipulation of neural structures. Herein, we describe the techniques of transclival, transphenoidal, transplanum, and transcribiform resections of anterior skull base meningiomas. Selected cases are presented. PMID:23730542

Conceptual transitions in methods of skull-photo superimposition that impact the reliability of identification: a review.

PubMed

Jayaprakash, Paul T

2015-01-01

Establishing identification during skull-photo superimposition relies on correlating the salient morphological features of an unidentified skull with those of a face-image of a suspected dead individual using image overlay processes. Technical progression in the process of overlay has included the incorporation of video cameras, image-mixing devices and software that enables real-time vision-mixing. Conceptual transitions occur in the superimposition methods that involve 'life-size' images, that achieve orientation of the skull to the posture of the face in the photograph and that assess the extent of match. A recent report on the reliability of identification using the superimposition method adopted the currently prevalent methods and suggested an increased rate of failures when skulls were compared with related and unrelated face images. The reported reduction in the reliability of the superimposition method prompted a review of the transition in the concepts that are involved in skull-photo superimposition. The prevalent popular methods for visualizing the superimposed images at less than 'life-size', overlaying skull-face images by relying on the cranial and facial landmarks in the frontal plane when orienting the skull for matching and evaluating the match on a morphological basis by relying on mix-mode alone are the major departures in the methodology that may have reduced the identification reliability. The need to reassess the reliability of the method that incorporates the concepts which have been considered appropriate by the practitioners is stressed. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature.

PubMed

Rychen, Jonathan; Croci, Davide; Roethlisberger, Michel; Nossek, Erez; Potts, Matthew; Radovanovic, Ivan; Riina, Howard; Mariani, Luigi; Guzman, Raphael; Zumofen, Daniel W

2018-05-01

Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approach-related complications of these so-called "keyhole craniotomies". We review pertinent articles retrieved by search in the PubMed/Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results. A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant. Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice. Copyright © 2018 Elsevier Inc. All rights reserved.

Bilambdoid and posterior sagittal synostosis: the Mercedes Benz syndrome.

PubMed

Moore, M H; Abbott, A H; Netherway, D J; Menard, R; Hanieh, A

1998-09-01

A consistent pattern of craniosynostosis in the sagittal and bilateral lambdoid sutures is described in three patients. The external cranial ridging associated with fusion of these sutures produces a characteristic triradiate, or "Mercedes Benz," appearance to the posterior skull. Locally marked growth restriction is evident in the posterior fossa with compensatory secondary expansion of the anterior fossa manifesting a degree of frontal bossing which mimics bicoronal synostosis. Although this appearance could lead to inadvertent surgery in the frontal region, attention to the occipital region with wide early suture excision and vault shaping is indicated.

[Thick and thin zones of the neurocranium, impressiones gyrorum and foramina parietalia in children and adults (author's transl)].

PubMed

Lang, J; Brückner, B

1981-01-01

At 102 skulls from adults and 67 skulls from children we have investigated 1) The postnatal changes of the thickness from basal parts of the Fossae craniales ant., med. et post. 2) The postnatal thickening and lateral shifting of the Processus clinoideus anterior. 3) The postnatal development at the superior side of the Canalis opticus. 4) Between the Os sphenoidale Clivus angle from newborn age to 17 years of life at 67 skulls. 5) The postnatal changes of the lateral angle at the Pars petrosa and its right-left-differences. 6) The postnatal thickening of the Calvaria (Squama frontalis - Tuber frontale, Os parietale - Tuber parietale). 7) The development, size and position of the Foramina parietalia. 8) The postnatal development of the Protuberantiae gyrorum and Sulci meningei.

[Application of neuroendoscope in the treatment of skull base chordoma].

PubMed

Zhang, Ya-Zhuo; Wang, Zong-Cheng; Zong, Xu-Yi; Wang, Xin-Sheng; Gui, Song-Bai; Zhao, Peng; Li, Chu-Zhong; He, Yue; Wang, Hong-Yun

2011-07-05

To further explore the application, approach, indication and prognosis of neuroendoscope treatment for skull base chordoma. A total of 101 patients of skull base chordoma were admitted at our hospital from May 2000 to April 2010. There were 59 males and 42 females. Their major clinical manifestations included headache, cranial nerve damage and dyspnea. They were classified according to the patterns of tumor growth: Type I (n = 13): tumor location at a single component of skull base, i. e. clivus or sphenoid sinus with intact cranial dura; Type II (n = 56): tumor involving more than two components of skull e. g clivus, sphenoid and nasal/oral cavity, etc. But there was no intracranial invasion; Type III (n = 32) : tumor extending widely and intradurally forming compression of brain stems and multiple cranial nerves. Based on the types of chordoma, different endoscopic approaches were employed, viz. transnasal, transoral, trans-subtemporal fossa and plus microsurgical craniotomy for staging in some complex cases. Among all patients, total resection was achieved (n = 19), subtotal (n = 58) and partial (n = 24). In partial resection cases, 16 cases were considered to be subtotal due to a second-stage operation. Most cases had conspicuous clinical improvements. Self-care recovery within one week post-operation accounted for 58.4%, two weeks 30.7%, one month 6.9% and more than one month 1.9%. Postoperative complications occurred in 13 cases (12.8%) and included CSF leakage (n = 4) cranial nerve palsy (n = 5), hemorrhagic nasal wounds (n = 3) and delayed intracranial hemorrhage (n = 1). All of these were cured or improved after an appropriate treatment. A follow-up of 6 - 60 months was conducted in 56 cases. Early detection and early treatment are crucial for achieving a better outcome in chordoma. Neuroendoscopic treatment plays an important role in managing those complicated cases. Precise endoscopic techniques plus different surgical approaches and staging procedures are required to improve the post-operative quality of life for patients.

Quantitative verification of the keyhole concept: a comparison of area of exposure in the parasellar region via supraorbital keyhole, frontotemporal pterional, and supraorbital approaches.

PubMed

Cheng, Cheng-Mao; Noguchi, Akio; Dogan, Aclan; Anderson, Gregory J; Hsu, Frank P K; McMenomey, Sean O; Delashaw, Johnny B

2013-02-01

This study was designed to determine if the "keyhole concept," proposed by Perneczky's group, can be verified quantitatively. Fourteen (3 bilateral and 8 unilateral) sides of embalmed latex-injected cadaveric heads were dissected via 3 sequential craniotomy approaches: supraorbital keyhole, frontotemporal pterional, and supraorbital. Three-dimensional cartesian coordinates were recorded using a stereotactic localizer. The orthocenter of the ipsilateral anterior clinoid process, the posterior clinoid process, and the contralateral anterior clinoid process are expressed as a center point (the apex). Seven vectors project from the apex to their corresponding target points in a radiating manner on the parasellar skull base. Each 2 neighboring vectors border what could be considered a triangle, and the total area of the 7 triangles sharing the same apex was geometrically expressed as the area of exposure in the parasellar region. Values are expressed as the mean ± SD (mm(2)). The total area of exposure was as follows: supraorbital keyhole 1733.1 ± 336.0, pterional 1699.3 ± 361.9, and supraorbital 1691.4 ± 342.4. The area of exposure on the contralateral side was as follows: supraorbital keyhole 602.2 ± 194.7, pterional 595.2 ± 228.0, and supraorbital 553.3 ± 227.2. The supraorbital keyhole skull flap was 2.0 cm(2), and the skull flap size ratio was 1:5:6.5 (supraorbital keyhole/pterional/supraorbital). The area of exposure of the parasellar region through the smaller supraorbital keyhole approach is as adequate as the larger pterional and supraorbital approaches. The keyhole concept can be verified quantitatively as follows: 1) a wide area of exposure on the skull base can be obtained through a small keyhole skull opening, and 2) the side opposite the opening can also be visualized.

3D printing and modelling of customized implants and surgical guides for non-human primates.

PubMed

Chen, Xing; Possel, Jessy K; Wacongne, Catherine; van Ham, Anne F; Klink, P Christiaan; Roelfsema, Pieter R

2017-07-15

Primate neurobiologists use chronically implanted devices such as pedestals for head stabilization and chambers to gain access to the brain and study its activity. Such implants are skull-mounted, and made from a hard, durable material, such as titanium. Here, we present a low-cost method of creating customized 3D-printed cranial implants that are tailored to the anatomy of individual animals. We performed pre-surgical computed tomography (CT) and magnetic resonance (MR) scans to generate three-dimensional (3D) models of the skull and brain. We then used 3D modelling software to design implantable head posts, chambers, and a pedestal anchorage base, as well as craniotomy guides to aid us during surgery. Prototypes were made from plastic or resin, while implants were 3D-printed in titanium. The implants underwent post-processing and received a coating of osteocompatible material to promote bone integration. Their tailored fit greatly facilitated surgical implantation, and eliminated the gap between the implant and the bone. To date, our implants remain robust and well-integrated with the skull. Commercial-off-the-shelf solutions typically come with a uniform, flat base, preventing them from sitting flush against the curved surface of the skull. This leaves gaps for fluid and tissue ingress, increasing the risk of microbial infection and tissue inflammation, as well as implant loss. The use of 3D printing technology enabled us to quickly and affordably create unique, complex designs, avoiding the constraints levied by traditional production methods, thereby boosting experimental success and improving the wellbeing of the animals. Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.

Opening the Blood-Brain Barrier with MR Imaging-guided Focused Ultrasound: Preclinical Testing on a Trans-Human Skull Porcine Model.

PubMed

Huang, Yuexi; Alkins, Ryan; Schwartz, Michael L; Hynynen, Kullervo

2017-01-01

Purpose To develop and test a protocol in preparation for a clinical trial on opening the blood-brain barrier (BBB) with magnetic resonance (MR) imaging-guided focused ultrasound for the delivery of chemotherapy drugs to brain tumors. Materials and Methods The procedures were approved by the institutional animal care committee. A trans-human skull porcine model was designed for the preclinical testing. Wide craniotomies were applied in 11 pigs (weight, approximately 15 kg). A partial human skull was positioned over the animal's brain. A modified clinical MR imaging-guided focused ultrasound brain system was used with a 3.0-T MR unit. The ultrasound beam was steered during sonications over a 3 × 3 grid at 3-mm spacing. Acoustic power levels of 3-20 W were tested. Bolus injections of microbubbles at 4 μL/kg were tested for each sonication. Levels of BBB opening, hemorrhage, and cavitation signal were measured with MR imaging, histologic examination, and cavitation receivers, respectively. A cavitation safety algorithm was developed on the basis of logistic regression of the measurements and tested to minimize the risk of hemorrhage. Results BBB openings of approximately 1 cm 3 in volume were visualized with gadolinium-enhanced MR imaging after sonication at an acoustic power of approximately 5 W. Gross examination of histologic specimens helped confirm Evans blue (bound to macromolecule albumin) extravasation, and hematoxylin-eosin staining helped detect only scattered extravasation of red blood cells. In cases where cavitation signals were higher than thresholds, sonications were terminated immediately without causing hemorrhage. Conclusion With a trans-human skull porcine model, this study demonstrated BBB opening with a 230-kHz system in preparation for a clinical trial. © RSNA, 2016 Online supplemental material is available for this article.

Trans-zygomatic middle cranial fossa approach to access lesions around the cavernous sinus and anterior parahippocampus: a minimally invasive skull base approach.

PubMed

Melamed, Itay; Tubbs, R Shane; Payner, Troy D; Cohen-Gadol, Aaron A

2009-08-01

Exposure of the cavernous sinus or anterior parahippocampus often involves a wide exposure of the temporal lobe and mobilization of the temporalis muscle associated with temporal lobe retraction. The authors present a cadaveric study to illustrate the feasibility, advantages and landmarks necessary to perform a trans-zygomatic middle fossa approach to lesions around the cavernous sinus and anterior parahippocampus. The authors performed bilateral trans-zygomatic middle fossae exposures to reach the cavernous sinus and parahippocampus in five cadavers (10 sides). We assessed the morbidity associated with this procedure and compared the indications, advantages, and disadvantages of this method versus more extensive skull base approaches. A vertical linear incision along the middle portion of the zygomatic arch was extended one finger breadth inferior to the inferior edge of the zygomatic arch. Careful dissection inferior to the arch allowed preservation of facial nerve branches. A zygomatic osteotomy was followed via a linear incision through the temporalis muscle and exposure of the middle cranial fossa floor. A craniotomy along the inferolateral temporal bone and middle fossa floor allowed extradural dissection along the middle fossa floor and exposure of the cavernous sinus including all three divisions of the trigeminal nerve. Intradural inspection demonstrated adequate exposure of the parahippocampus. Exposure of the latter required minimal or no retraction of the temporal lobe. The trans-zygomatic middle fossa approach is a simplified skull base exposure using a linear incision, which may avoid the invasivity of more extensive skull base approaches while providing an adequate corridor for resection of cavernous sinus and parahippocampus lesions. The advantages of this approach include its efficiency, ease, minimalism, preservation of the temporalis muscle, and minimal retraction of the temporal lobe.

Mechanical Evaluation of Retinal Damage Associated With Blunt Craniomaxillofacial Trauma: A Simulation Analysis.

PubMed

Geng, Xiaoqi; Liu, Xiaoyu; Wei, Wei; Wang, Yawei; Wang, Lizhen; Chen, Kinon; Huo, Hongqiang; Zhu, Yuanjie; Fan, Yubo

2018-05-01

To evaluate retinal damage as the result of craniomaxillofacial trauma and explain its pathogenic mechanism using finite element (FE) simulation. Computed tomography (CT) images of an adult man were obtained to construct a FE skull model. A FE skin model was built to cover the outer surface of the skull model. A previously validated FE right eye model was symmetrically copied to create a FE left eye model, and both eye models were assembled to the skull model. An orbital fat model was developed to fill the space between the eye models and the skull model. Simulations of a ball-shaped object striking the frontal bone, temporal bone, brow, and cheekbones were performed, and the resulting absorption of the impact energy, intraocular pressure (IOP), and strains on the macula and ora serrata were analyzed to evaluate retinal injuries. Strain was concentrated in the macular regions (0.18 in average) of both eyes when the frontal bone was struck. The peak strain on the macula of the struck-side eye was higher than that of the other eye (>100%) when the temporal bone was struck, whereas there was little difference (<10%) between the two eyes when the brow and cheekbones were struck. Correlation analysis showed that the retinal strain time histories were highly correlated with the IOP time histories ( r > 0.8 and P = 0.000 in all simulation cases). The risk of retinal damage is variable in craniomaxillofacial trauma depending on the struck region, and the damage is highly related to IOP variation caused by indirect blunt eye trauma. This finite element eye model allows us to evaluate and understand the indirect ocular injury mechanisms in craniomaxillofacial trauma for better clinical diagnosis and treatment.

Penetrating ballistic-like frontal brain injury caused by a metallic rod.

PubMed

Pascual, J M; Navas, M; Carrasco, R

2009-06-01

Penetrating non-missile intracranial injuries caused by metallic foreign bodies are very rare among the civilian population. We present a unique instance of a severe, high-energy, penetrating orbitocranial injury caused by a solid metallic rod that corresponded to the spray valve lever handle of a kitchen sink pre-rinse spray tap, which was fractured and projected at high speed for an unknown reason. To our knowledge, this is the first report of a high-energy, penetrating brain injury caused by such an object. After careful radiological evaluation of the shape and position of the foreign object, a combined right frontal craniotomy and supraorbital osteotomy was performed in order to achieve safe removal of the metal bar. Successful surgical treatment of an orbitocranial injury caused by a similar object has not previously been reported.

On the integral use of foundational concepts in verifying validity during skull-photo superimposition.

PubMed

Jayaprakash, Paul T

2017-09-01

Often cited reliability test on video superimposition method integrated scaling face-images in relation to skull-images, tragus-auditory meatus relationship in addition to exocanthion-Whitnall's tubercle relationship when orientating the skull-image and wipe mode imaging in addition to mix mode imaging when obtaining skull-face image overlay and evaluating the goodness of match. However, a report that found higher false positive matches in computer assisted superimposition method transited from the above foundational concepts and relied on images of unspecified sizes that are lesser than 'life-size', frontal plane landmarks in the skull- and face- images alone for orientating the skull-image and mix images alone for evaluating the goodness of match. Recently, arguing the use of 'life-size' images as 'archaic', the authors who tested the reliability in the computer assisted superimposition method have denied any method transition. This article describes that the use of images of unspecified sizes at lesser than 'life-size' eliminates the only possibility to quantify parameters during superimposition which alone enables dynamic skull orientation when overlaying a skull-image with a face-image in an anatomically acceptable orientation. The dynamic skull orientation process mandatorily requires aligning the tragus in the 2D face-image with the auditory meatus in the 3D skull-image for anatomically orientating the skull-image in relation to the posture in the face-image, a step not mentioned by the authors describing the computer assisted superimposition method. Furthermore, mere reliance on mix type images during image overlay eliminates the possibility to assess the relationship between the leading edges of the skull- and face-image outlines as also specific area match among the corresponding craniofacial organs during superimposition. Indicating the possibility of increased false positive matches as a consequence of the above method transitions, the need for testing the reliability in the superimposition method adopting concepts that are considered safe is stressed. Copyright © 2017 Elsevier B.V. All rights reserved.

Postoperative Neurosurgical Infection Rates After Shared-Resource Intraoperative Magnetic Resonance Imaging: A Single-Center Experience with 195 Cases.

PubMed

Dinevski, Nikolaj; Sarnthein, Johannes; Vasella, Flavio; Fierstra, Jorn; Pangalu, Athina; Holzmann, David; Regli, Luca; Bozinov, Oliver

2017-07-01

To determine the rate of surgical-site infections (SSI) in neurosurgical procedures involving a shared-resource intraoperative magnetic resonance imaging (ioMRI) scanner at a single institution derived from a prospective clinical quality management database. All consecutive neurosurgical procedures that were performed with a high-field, 2-room ioMRI between April 2013 and June 2016 were included (N = 195; 109 craniotomies and 86 endoscopic transsphenoidal procedures). The incidence of SSIs within 3 months after surgery was assessed for both operative groups (craniotomies vs. transsphenoidal approach). Of the 109 craniotomies, 6 patients developed an SSI (5.5%, 95% confidence interval [CI] 1.2-9.8%), including 1 superficial SSI, 2 cases of bone flap osteitis, 1 intracranial abscess, and 2 cases of meningitis/ventriculitis. Wound revision surgery due to infection was necessary in 4 patients (4%). Of the 86 transsphenoidal skull base surgeries, 6 patients (7.0%, 95% CI 1.5-12.4%) developed an infection, including 2 non-central nervous system intranasal SSIs (3%) and 4 cases of meningitis (5%). Logistic regression analysis revealed that the likelihood of infection significantly decreased with the number of operations in the new operational setting (odds ratio 0.982, 95% CI 0.969-0.995, P = 0.008). The use of a shared-resource ioMRI in neurosurgery did not demonstrate increased rates of infection compared with the current available literature. The likelihood of infection decreased with the accumulating number of operations, underlining the importance of surgical staff training after the introduction of a shared-resource ioMRI. Copyright © 2017 Elsevier Inc. All rights reserved.

Effects of Lignocaine Administered Intravenously or Intratracheally on Airway and Hemodynamic Responses during Emergence and Extubation in Patients Undergoing Elective Craniotomies in Supine Position.

PubMed

Shabnum, Tabasum; Ali, Zulfiqar; Naqash, Imtiaz Ahmad; Mir, Aabid Hussain; Azhar, Khan; Zahoor, Syed Amer; Mir, Abdul Waheed

2017-01-01

Sympathoadrenergic responses during emergence and extubation can lead to an increase in heart rate (HR) and blood pressure whereas increased airway responses may lead to coughing and laryngospasm. The aim of our study was to compare the effects of lignocaine administered intravenously (IV) or intratracheally on airway and hemodynamic responses during emergence and extubation in patients undergoing elective craniotomies. Sixty patients with physical status American Society of Anaesthesiologists Classes I and II aged 18-70 years, scheduled to undergo elective craniotomies were included. The patients were randomly divided into three groups of twenty patients; Group 1 receiving IV lignocaine and intratracheal placebo (IV group), Group 2 receiving intratracheal lignocaine and IV placebo (I/T group), and Group 3 receiving IV and intratracheal placebo (placebo group). The tolerance to the endotracheal tube was monitored, and number of episodes of cough was recorded during emergence and at the time of extubation. Hemodynamic parameters such as HR and blood pressure (systolic, diastolic, mean arterial pressure) were also recorded. There was a decrease of HR in both IV and intratracheal groups in comparison with placebo group ( P < 0.005). Rise in blood pressure (systolic blood pressure, diastolic blood pressure and mean arterial pressure) was comparable in both Groups 1 and 2 but was lower in comparison with placebo group ( P < 0.005). Cough suppression was comparable in all the three groups. Grade III cough (15%) was documented only in placebo group. Both IV and intratracheal lignocaine are effective in attenuation of hemodynamic response if given within 20 min from skull pin removal to extubation. There was comparable cough suppression through intratracheal route and IV routes than the placebo group.

[Sellar hemangiopericytoma. A case report].

PubMed

Ksira, I; Berhouma, M; Jemel, H; Khouja, N; Khaldi, M

2006-06-01

Primary central nervous system hemangiopericytoma is rare, accounting for less than 1% of primary central nervous system tumors. Diagnosis is histological. Treatment is surgical excision, followed by radiotherapy. Long-term follow-up is mandatory for these tumors with a high potential for recurrence and metastasis. The sellar location is very rare, and can be confused with pituitary adenoma. We report the case of a patient presenting a sellar hemangiopericytoma, who underwent surgery via a transsphenoidal approach, then right frontal craniotomy followed by radiotherapy. There was no recurrence at one year follow-up.

The skull roof tracks the brain during the evolution and development of reptiles including birds.

PubMed

Fabbri, Matteo; Mongiardino Koch, Nicolás; Pritchard, Adam C; Hanson, Michael; Hoffman, Eva; Bever, Gabriel S; Balanoff, Amy M; Morris, Zachary S; Field, Daniel J; Camacho, Jasmin; Rowe, Timothy B; Norell, Mark A; Smith, Roger M; Abzhanov, Arhat; Bhullar, Bhart-Anjan S

2017-10-01

Major transformations in brain size and proportions, such as the enlargement of the brain during the evolution of birds, are accompanied by profound modifications to the skull roof. However, the hypothesis of concerted evolution of shape between brain and skull roof over major phylogenetic transitions, and in particular of an ontogenetic relationship between specific regions of the brain and the skull roof, has never been formally tested. We performed 3D morphometric analyses to examine the deep history of brain and skull-roof morphology in Reptilia, focusing on changes during the well-documented transition from early reptiles through archosauromorphs, including nonavian dinosaurs, to birds. Non-avialan taxa cluster tightly together in morphospace, whereas Archaeopteryx and crown birds occupy a separate region. There is a one-to-one correspondence between the forebrain and frontal bone and the midbrain and parietal bone. Furthermore, the position of the forebrain-midbrain boundary correlates significantly with the position of the frontoparietal suture across the phylogenetic breadth of Reptilia and during the ontogeny of individual taxa. Conservation of position and identity in the skull roof is apparent, and there is no support for previous hypotheses that the avian parietal is a transformed postparietal. The correlation and apparent developmental link between regions of the brain and bony skull elements are likely to be ancestral to Tetrapoda and may be fundamental to all of Osteichthyes, coeval with the origin of the dermatocranium.

Facial artery musculomucosal flap for reconstruction of skull base defects: a cadaveric study.

PubMed

Xie, Liyue; Lavigne, François; Rahal, Akram; Moubayed, Sami Pierre; Ayad, Tareck

2013-08-01

Failure in skull base defects reconstruction following tumor resection can have serious consequences such as ascending meningitis and pneumocephaly. The nasoseptal flap showed a very low incidence of cerebrospinal fluid leak but is not always available. The superiorly pedicled facial artery musculomucosal (FAMM) flap has been successfully used for reconstruction of head and neck defects. Our objective is to show that the FAMM flap can be used as a new alternative in skull base reconstruction. Cadaveric study. Feasibility. Thirteen specimens underwent bilateral FAMM flap dissection. Two new modifications of the traditional FAMM flap have been developed. Feasibility in FAMM flap transfer to the skull base was investigated through endoscopic skull base dissection and maxillectomy in four specimens. Measurements were recorded for each harvested flap. The mean surface area of the modified FAMM flap efficient for reconstruction was 15.90 cm(2) . The flaps easily covered the simulated defects of the frontal sinus and the fovea ethmoidalis areas. Modifications of the traditional FAMM flap were necessary for a tension-free coverage of the planum sphenoidale and sella turcica. The FAMM flap holds high potential as a new alternative vascular flap in skull base reconstruction. However, it has not been used in patients yet and should be considered only when other options are not available. New modifications developed in this article can elongate the traditional FAMM flap, potentially contributing to a tighter seal of the skull base defect than FAMM flap alone. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Effect of skull flexural properties on brain response during dynamic head loading - biomed 2013.

PubMed

Harrigan, T P; Roberts, J C; Ward, E E; Carneal, C M; Merkle, A C

2013-01-01

The skull-brain complex is typically modeled as an integrated structure, similar to a fluid-filled shell. Under dynamic loads, the interaction of the skull and the underlying brain, cerebrospinal fluid, and other tissue produces the pressure and strain histories that are the basis for many theories meant to describe the genesis of traumatic brain injury. In addition, local bone strains are of interest for predicting skull fracture in blunt trauma. However, the role of skull flexure in the intracranial pressure response to blunt trauma is complex. Since the relative time scales for pressure and flexural wave transmission across the skull are not easily separated, it is difficult to separate out the relative roles of the mechanical components in this system. This study uses a finite element model of the head, which is validated for pressure transmission to the brain, to assess the influence of skull table flexural stiffness on pressure in the brain and on strain within the skull. In a Human Head Finite Element Model, the skull component was modified by attaching shell elements to the inner and outer surfaces of the existing solid elements that modeled the skull. The shell elements were given the properties of bone, and the existing solid elements were decreased so that the overall stiffness along the surface of the skull was unchanged, but the skull table bending stiffness increased by a factor of 2.4. Blunt impact loads were applied to the frontal bone centrally, using LS-Dyna. The intracranial pressure predictions and the strain predictions in the skull were compared for models with and without surface shell elements, showing that the pressures in the mid-anterior and mid-posterior of the brain were very similar, but the strains in the skull under the loads and adjacent to the loads were decreased 15% with stiffer flexural properties. Pressure equilibration to nearly hydrostatic distributions occurred, indicating that the important frequency components for typical impact loading are lower than frequencies based on pressure wave propagation across the skull. This indicates that skull flexure has a local effect on intracranial pressures but that the integrated effect of a dome-like structure under load is a significant part of load transfer in the skull in blunt trauma.

A neurosurgical simulation of skull base tumors using a 3D printed rapid prototyping model containing mesh structures.

PubMed

Kondo, Kosuke; Harada, Naoyuki; Masuda, Hiroyuki; Sugo, Nobuo; Terazono, Sayaka; Okonogi, Shinichi; Sakaeyama, Yuki; Fuchinoue, Yutaka; Ando, Syunpei; Fukushima, Daisuke; Nomoto, Jun; Nemoto, Masaaki

2016-06-01

Deep regions are not visible in three-dimensional (3D) printed rapid prototyping (RP) models prepared from opaque materials, which is not the case with translucent images. The objectives of this study were to develop an RP model in which a skull base tumor was simulated using mesh, and to investigate its usefulness for surgical simulations by evaluating the visibility of its deep regions. A 3D printer that employs binder jetting and is mainly used to prepare plaster models was used. RP models containing a solid tumor, no tumor, and a mesh tumor were prepared based on computed tomography, magnetic resonance imaging, and angiographic data for four cases of petroclival tumor. Twelve neurosurgeons graded the three types of RP model into the following four categories: 'clearly visible,' 'visible,' 'difficult to see,' and 'invisible,' based on the visibility of the internal carotid artery, basilar artery, and brain stem through a craniotomy performed via the combined transpetrosal approach. In addition, the 3D positional relationships between these structures and the tumor were assessed. The internal carotid artery, basilar artery, and brain stem and the positional relationships of these structures with the tumor were significantly more visible in the RP models with mesh tumors than in the RP models with solid or no tumors. The deep regions of PR models containing mesh skull base tumors were easy to visualize. This 3D printing-based method might be applicable to various surgical simulations.

Porcine pilot study of MRI-guided HIFU treatment for neonatal intraventricular hemorrhage (IVH)

NASA Astrophysics Data System (ADS)

Looi, Thomas; Waspe, Adam; Mougenot, Charles; Amaral, Joao; Temple, Michael; Hynynen, Kullervo; Drake, James

2012-11-01

Intraventricular hemorrhage (IVH) occurs in 15% of premature babies and 50% of IVH cases progress to posthemorrhagic ventricular dilation due to large blood clots forming in the ventricles. Existing treatments such as tissue plasminogen activator (tPA) and surgical intervention have severe side effects in paediatric patients that include excessive bleeding and complications. This study investigates the feasibility of MR-HIFU for sonothrombolysis of blood clots from IVH using natural acoustic windows, known as fontanelles, in the skulls of newborns. The study involved 2 elements: a phantom study to examine beam limitations and acoustic properties, and an in-vivo porcine study. A phantom skull was created from sample patient data and was used to analyze reachability of the Philips Sonavelle system. Acoustic measurements of the phantom (attenuation of 5-14 dB and speed of sound of 1722-2965 m/s) indicated the phantom effectively mimics neonatal skull bone. For the ex-vivo studies, a porcine clot was created and sonicated for 5 mins at 500W with a 0.5% duty cycle. For the in-vivo experiment, a vertex craniotomy was performed and porcine blood was injected into the lateral ventricle under ultrasound guidance. Sonication using the prior parameters induced cavitation and post-sonication T1 and T2 images verified clot lysis. Further H&E analysis showed no presence of blood in the ventricles. These positive results show that MR-HIFU has potential as a noninvasive tool for sonothrombolysis of neonatal IVH clots.

Collaborative voxel-based surgical virtual environments.

PubMed

Acosta, Eric; Muniz, Gilbert; Armonda, Rocco; Bowyer, Mark; Liu, Alan

2008-01-01

Virtual Reality-based surgical simulators can utilize Collaborative Virtual Environments (C-VEs) to provide team-based training. To support real-time interactions, C-VEs are typically replicated on each user's local computer and a synchronization method helps keep all local copies consistent. This approach does not work well for voxel-based C-VEs since large and frequent volumetric updates make synchronization difficult. This paper describes a method that allows multiple users to interact within a voxel-based C-VE for a craniotomy simulator being developed. Our C-VE method requires smaller update sizes and provides faster synchronization update rates than volumetric-based methods. Additionally, we address network bandwidth/latency issues to simulate networked haptic and bone drilling tool interactions with a voxel-based skull C-VE.

A chronic scheme of cranial window preparation to study pial vascular reactivity in murine cerebral malaria

PubMed Central

Ong, Peng Kai; Meays, Diana; Frangos, John A.; Carvalho, Leonardo J.M.

2013-01-01

Objective The acute implantation of a cranial window for studying cerebroarteriolar reactivity in living animals involves a highly surgically-invasive craniotomy procedure at the time of experimentation, which limits its application in severely ill animals such as in the experimental murine model of cerebral malaria (ECM). To overcome this problem, a chronic window implantation scheme was designed and implemented. Methods A partial craniotomy is first performed by creating a skull bone flap in the healthy mice, which are then left to recover for 1–2 weeks, followed by infection to induce ECM. Uninfected animals are utilized as control. When cranial superfusion is needed, the bone flap is retracted and window implantation completed by assembling a perfusion chamber for compound delivery to the exposed brain surface. The presurgical step is intended to minimize surgical trauma on the day of experimentation. Results Chronic preparations in uninfected mice exhibited remarkably improved stability over acute ones by significantly reducing periarteriolar tissue damage and enhancing cerebroarteriolar dilator responses. The chronic scheme was successfully implemented in ECM mice which unveiled novel preliminary insights on impaired cerebroarteriolar reactivity and eNOS dysfunction. Conclusion The chronic scheme presents an innovative approach for advancing our mechanistic understanding on cerebrovascular dysfunction in ECM. PMID:23279271

Tumor location and IDH1 mutation may predict intraoperative seizures during awake craniotomy.

PubMed

Gonen, Tal; Grossman, Rachel; Sitt, Razi; Nossek, Erez; Yanaki, Raneen; Cagnano, Emanuela; Korn, Akiva; Hayat, Daniel; Ram, Zvi

2014-11-01

Intraoperative seizures during awake craniotomy may interfere with patients' ability to cooperate throughout the procedure, and it may affect their outcome. The authors have assessed the occurrence of intraoperative seizures during awake craniotomy in regard to tumor location and the isocitrate dehydrogenase 1 (IDH1) status of the tumor. Data were collected in 137 consecutive patients who underwent awake craniotomy for removal of a brain tumor. The authors performed a retrospective analysis of the incidence of seizures based on the tumor location and its IDH1 mutation status, and then compared the groups for clinical variables and surgical outcome parameters. Tumor location was strongly associated with the occurrence of intraoperative seizures. Eleven patients (73%) with tumor located in the supplementary motor area (SMA) experienced intraoperative seizures, compared with 17 (13.9%) with tumors in the other three non-SMA brain regions (p < 0.0001). Interestingly, there was no significant association between history of seizures and tumor location (p = 0.44). Most of the patients (63.6%) with tumor in the SMA region harbored an IDH1 mutation compared with those who had tumors in non-SMA regions. Thirty-one of 52 patients (60%) with a preoperative history of seizures had an IDH1 mutation (p = 0.02), and 15 of 22 patients (68.2%) who experienced intraoperative seizures had an IDH1 mutation (p = 0.03). In a multivariate analysis, tumor location was found as a significant predictor of intraoperative seizures (p = 0.002), and a trend toward IDH1 mutation as such a predictor was found as well (p = 0.06). Intraoperative seizures were not associated with worse outcome. Patients with tumors located in the SMA are more prone to develop intraoperative seizures during awake craniotomy compared with patients who have a tumor in non-SMA frontal areas and other brain regions. The IDH1 mutation was more common in SMA region tumors compared with other brain regions, and may be an additional risk factor for the occurrence of intraoperative seizures.

Calvarial bone cavernous hemangioma with intradural invasion: An unusual aggressive course-Case report and literature review.

PubMed

Nasi, Davide; Somma, Lucia di; Iacoangeli, Maurizio; Liverotti, Valentina; Zizzi, Antonio; Dobran, Mauro; Gladi, Maurizio; Scerrati, Massimo

2016-01-01

Cavernous hemangioma of the skull is a rare pathological diagnosis, accounting for 0.2% of bone tumors and 7% of skull tumors. Usually calvarial bone cavernous hemangioma are associated with a benign clinical course and, despite their enlargement and subsequent erosion of the surrounding bone, the inner table of the skull remains intact and the lesion is completely extracranial. The authors present the unique case of a huge left frontal bone cavernous malformation with intradural extension and brain compression determining a right hemiparesis. Calvarial cavernous hemangiomas are benign tumors. They arise from vessels in the diploic space and tend to involve the outer table of the skull with relative sparing of the inner table. More extensive involvement of the inner table and extradural space is very unusual and few cases are reported in literature. To the best of our knowledge, intradural invasion of calvarial hemangioma has not been previously reported. Our case highlights the possibility of an aggressive course of this rare benign pathology. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Calvarial bone cavernous hemangioma with intradural invasion: An unusual aggressive course—Case report and literature review

PubMed Central

Nasi, Davide; Somma, Lucia di; Iacoangeli, Maurizio; Liverotti, Valentina; Zizzi, Antonio; Dobran, Mauro; Gladi, Maurizio; Scerrati, Massimo

2016-01-01

Introduction Cavernous hemangioma of the skull is a rare pathological diagnosis, accounting for 0.2% of bone tumors and 7% of skull tumors. Usually calvarial bone cavernous hemangioma are associated with a benign clinical course and, despite their enlargement and subsequent erosion of the surrounding bone, the inner table of the skull remains intact and the lesion is completely extracranial. Presentation of a case The authors present the unique case of a huge left frontal bone cavernous malformation with intradural extension and brain compression determining a right hemiparesis. Discussion Calvarial cavernous hemangiomas are benign tumors. They arise from vessels in the diploic space and tend to involve the outer table of the skull with relative sparing of the inner table. More extensive involvement of the inner table and extradural space is very unusual and few cases are reported in literature. To the best of our knowledge, intradural invasion of calvarial hemangioma has not been previously reported. Conclusion Our case highlights the possibility of an aggressive course of this rare benign pathology. PMID:27061482

Earliest Cranio-Encephalic Trauma from the Levantine Middle Palaeolithic: 3D Reappraisal of the Qafzeh 11 Skull, Consequences of Pediatric Brain Damage on Individual Life Condition and Social Care

PubMed Central

Coqueugniot, Hélène; Dutour, Olivier; Arensburg, Baruch; Duday, Henri; Vandermeersch, Bernard; Tillier, Anne-marie

2014-01-01

The Qafzeh site (Lower Galilee, Israel) has yielded the largest Levantine hominin collection from Middle Palaeolithic layers which were dated to circa 90–100 kyrs BP or to marine isotope stage 5b–c. Within the hominin sample, Qafzeh 11, circa 12–13 yrs old at death, presents a skull lesion previously attributed to a healed trauma. Three dimensional imaging methods allowed us to better explore this lesion which appeared as being a frontal bone depressed fracture, associated with brain damage. Furthermore the endocranial volume, smaller than expected for dental age, supports the hypothesis of a growth delay due to traumatic brain injury. This trauma did not affect the typical human brain morphology pattern of the right frontal and left occipital petalia. It is highly probable that this young individual suffered from personality and neurological troubles directly related to focal cerebral damage. Interestingly this young individual benefited of a unique funerary practice among the south-western Asian burials dated to Middle Palaeolithic. PMID:25054798

Unusual presentation of a skull base mass lesion in sarcoidosis mimicking malignant neoplasm: a case report.

PubMed

Shijo, Katsunori; Moro, Nobuhiro; Sasano, Mari; Watanabe, Mitsuru; Yagasaki, Hiroshi; Takahashi, Shori; Homma, Taku; Yoshino, Atsuo

2018-05-29

Sarcoidosis is a multi-organ disease of unknown etiology characterised by the presence of epithelioid granulomas, without caseous necrosis. Systemic sarcoidosis is rare among children, while neurosarcoidosis in children is even rarer whether it is systemic or not. We described the case of a 12-year-old boy who presented with monocular vision loss accompanied by unusual MRI features of an extensive meningeal infiltrating mass lesion. The patient underwent surgical resection (biopsy) via a frontotemporal craniotomy to establish a definitive diagnosis based on the histopathology, since neurosarcoidosis remains a very difficult diagnosis to establish from neuroradiogenic imagings. Based on the histopathology of the resected mass lesion, neurosarcoidosis was diagnosed. On follow-up after 3 months of steroid therapy, the patient displayed a good response on the imaging studies. MRI revealed that the preexisting mass lesion had regressed extremely. We also conducted a small literature review on imaging studies, manifestations, appropriate treatments, etc., in particular neurosarcoidosis including children. Although extremely rare, neurosarcoidosis, even in children, should be considered in the differential diagnosis of skull base mass lesions to avoid unnecessary aggressive surgery and delay in treatment, since surgery may have little role in the treatment of sarcoidosis.

Remote cerebellar haemorrhage after placement of an external ventricular drainage for acute hydrocephalus: A case report.

PubMed

Caldeira, I; Lavrador, J; Basílio, G; Sousa, R; Reimão, S

2017-03-01

Remote cerebellar haemorrhage (RCH) is a rare complication following a craniotomy. This generally benign phenomenon is an identifiable complication of supratentorial craniotomies and should not be mistaken with other pathologies. The most common presenting symptom is a decrease in the level of consciousness but in some cases the RCH may be asymptomatic and accidentally discovered in follow-up CT scans. A 70-year-old man was admitted to our emergency department with sudden mental status deterioration. A head CT scan was carried out and an acute hydrocephalus was diagnosed. The patient was transferred to the operating room for external ventricular drainage (EVD) placement via a frontal burr-hole. At 24hours, the patient made a complete neurological recovery. On third postoperative day, a follow-up CT scan showed an asymptomatic right remote cerebellar haemorrhage. The MRI assessment confirmed the diagnosis. The EVD was removed on the 6th postoperative day and the patient was discharged after one week with no further symptoms. This case report is the first documented case, to our knowledge, of a remote cerebellar haemorrhage after placement of external ventricular drainage via a frontal burr-hole. The precise aetiology of remote cerebellar haemorrhage remains unclear. One of the most accepted theories is the "cerebellar sag" explanation, which defends hypothesis that peri-operative over drainage of cerebrospinal fluid (CSF) is the main mechanism involved. Further investigation is required to understand the pathogenesis and risk factors for the occurrence of this phenomenon. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Neurosurgical management of L-asparaginase induced haemorrhagic stroke

PubMed Central

Ogbodo, Elisha; Kaliaperumal, Chandrasekaran; O’Sullivan, Michael

2012-01-01

The authors describe a case of L-asparaginase induced intracranial thrombosis and subsequent haemorrhage in a newly diagnosed 30-year-old man with acute lymphoblastic leukaemia who was successfully managed by surgical intervention. At presentation, he had a Glasgow Coma Score of 7/15, was aphasic and had dense right hemiplegia. Neuroimaging revealed an acute anterior left middle cerebral artery infarct with parenchymal haemorrhagic conversion, mass effect and subfalcine herniation. He subsequently underwent left frontal craniotomy and evacuation of large frontal haematoma and decompressive craniectomy for cerebral oedema. Six months postoperatively he underwent titanium cranioplasty. He had made good clinical recovery and is currently mobilising independently with mild occasional episodes of expressive dysphasia, difficulty with fine motor movement on the right side, and has remained seizure free. This is the first documented case of L-asparaginase induced haemorrhagic stroke managed by neurosurgical intervention. The authors emphasise the possible role of surgery in managing chemotherapy induced intracranial complications. PMID:22605598

Pathologic Progression, Possible Origin, and Management of Multiple Primary Intracranial Neuroendocrine Carcinomas.

PubMed

Cao, Jingwei; Xu, Wenzhe; Du, Zhenhui; Sun, Bin; Li, Feng; Liu, Yuguang

2017-10-01

Primary intracranial neuroendocrine carcinomas (NECs) are extremely rare malignant tumors with no previous reports of multiple ones in the literatures. The clinical presentation, preoperative and reexamined magnetic resonance imaging findings, as well as histopathologic studies of a 56-year-old female subject with multiple intracranial NECs mimicking multiple intracranial meningiomas, who underwent 3 operations with left parietal craniotomy, right occipital parietal craniotomy, and left frontal craniotomy, separately and chronologically, are presented in this article. Noteworthy, the first and second tumors were confirmed as NECs exhibiting histologic characteristics of typical anaplastic meningiomas with features of whorl formation, while the third tumor was a typical NEC with features of organoid cancer nests. In other words, the first 2 lesions were diagnosed as meningioma as opposed to NEC. It was only after the third surgery that the pathology for the first 2 cases was reviewed and had a revised diagnosis. After the third surgical resection, the patient further received whole brain radiotherapy and systemic chemotherapy (temozolomide combined with YH-16). At her 10-month follow-up, the patient achieved a good outcome. Multiple primary intracranial NECs are extremely rare. The tumor might be of arachnoidal or leptomeningeal origin, with histologic patterns that might lead to transformation and/or progression. Maximal surgical resection is warranted for symptomatic mass effect. Postoperative adjuvant treatments including radiotherapy and chemotherapy should be a recommended therapeutic modality. Copyright © 2017 Elsevier Inc. All rights reserved.

Frontal sinus parameters in computed tomography and sex determination.

PubMed

Akhlaghi, Mitra; Bakhtavar, Khadijeh; Moarefdoost, Jhale; Kamali, Artin; Rafeifar, Shahram

2016-03-01

The frontal sinus is a sturdy part of the skull that is likely to be retrieved for forensic investigations. We evaluated frontal sinus parameters in paranasal sinus computed tomography (CT) images for sex determination. The study was conducted on 200 normal paranasal sinus CT images of 100 men and 100 women of Persian origin. We categorized the studied population into three age groups of 20-34, 35-49 and ⩾ 50 years. The number of partial septa in the right frontal sinus and the maximum height and width were significantly different between the two sexes. The highest precision for sex determination was for the maximum height of the left frontal sinus (61.3%). In the 20-34 years age-group, height and width of the frontal sinus were significantly different between the two sexes and the height of the left sinus had the highest precision (60.8%). In the 35-49 years age-group, right anterior-posterior diameter had a sex determination precision of 52.3%. No frontal sinus parameter reached a statistically significant level for sex determination in the ⩾ 50 years age-group. The number of septa and scallopings were not useful in sex determination. Frontal sinus parameters did not have a high precision in sex determination among Persian adults. Copyright © 2016. Published by Elsevier Ireland Ltd.

Functional Brain Activation in Response to a Clinical Vestibular Test Correlates with Balance

PubMed Central

Noohi, Fatemeh; Kinnaird, Catherine; DeDios, Yiri; Kofman, Igor S.; Wood, Scott; Bloomberg, Jacob; Mulavara, Ajitkumar; Seidler, Rachael

2017-01-01

The current study characterizes brain fMRI activation in response to two modes of vestibular stimulation: Skull tap and auditory tone burst. The auditory tone burst has been used in previous studies to elicit either a vestibulo-spinal reflex [saccular-mediated colic Vestibular Evoked Myogenic Potentials (cVEMP)], or an ocular muscle response [utricle-mediated ocular VEMP (oVEMP)]. Research suggests that the skull tap elicits both saccular and utricle-mediated VEMPs, while being faster and less irritating for subjects than the high decibel tones required to elicit VEMPs. However, it is not clear whether the skull tap and auditory tone burst elicit the same pattern of brain activity. Previous imaging studies have documented activity in the anterior and posterior insula, superior temporal gyrus, inferior parietal lobule, inferior frontal gyrus, and the anterior cingulate cortex in response to different modes of vestibular stimulation. Here we hypothesized that pneumatically powered skull taps would elicit a similar pattern of brain activity as shown in previous studies. Our results provide the first evidence of using pneumatically powered skull taps to elicit vestibular activity inside the MRI scanner. A conjunction analysis revealed that skull taps elicit overlapping activation with auditory tone bursts in the canonical vestibular cortical regions. Further, our postural control assessments revealed that greater amplitude of brain activation in response to vestibular stimulation was associated with better balance control for both techniques. Additionally, we found that skull taps elicit more robust vestibular activity compared to auditory tone bursts, with less reported aversive effects, highlighting the utility of this approach for future clinical and basic science research. PMID:28344549

[A case of frontal lobe syndrome of post-traumatic origin].

PubMed

Gadecki, W; Ramsz-Walecka, I; Tomczyszyn, E

1999-01-01

The paper discusses the case of a patient who was subjected to forensic and psychiatric observation and was charged with appropriation of money to the detriment of the company she worked for by District Public Prosecutor's Office. History data indicate that she was employed in the said company over the period of 20 years as an accountant and until the disclosure of the crime she had had the company's full confidence. She enjoyed a fine reputation at the place of her residence as well. Several months before undertaking criminal actions she had sustained a head and chest injure as a result of a car accident. She was not subjected to hospitalisation then. Before she had not been penalized administratively or legally. She had not suffered from head injuries with a loss of consciousness. During forensic and psychiatric observation, psychiatric, psychological, neurological and electroencephalographic examinations were carried out, skull and chest plain films were taken and computerised tomography of head was conducted. Clinically it was diagnosed as a frontal organic brain damage syndrome complicated by depression. Experts' examinations were steered by psychopathological image, especially axial symptoms of defective function of the frontal lobe, i.e. lack of initiative and spontaneity, deficiency of higher emotions, decline of criticism and lowering of psychomotor drive. Although psychological examination showed that intelligence quotient and the results of 'organic tests' were within normal range, qualitative analysis of the structure of mental functions disclosed impairment of abstract thinking, especially using associative processes. Essential data were gathered from computerised tomography of head which demonstrated cortical atrophy of frontal and temporal lobes and pericentral gyri. However, neurological and electroencephalographic examinations and skull plain film did not bring any significant information.

68Gallium-Arginine-Glycine-Aspartic Acid and 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Chondroblastic Osteosarcoma of the Skull.

PubMed

Orunmuyi, Akintunde; Modiselle, Moshe; Lengana, Thabo; Ebenhan, Thomas; Vorster, Mariza; Sathekge, Mike

2017-09-01

We report the case of a 32 year-old male with Chondroblastic Osteosarcoma of the skull, which was imaged with both 18 [F]fluorodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) and 68 Gallium-arginine-glycine-aspartic acid ( 68 Ga-RGD) PET/CT. The 18 F-FDG PET/CT did not demonstrate the tumour, whereas the 68 Ga-RGD PET/CT clearly depicted a left-sided frontal tumour. 68 Ga-RGD PET/CT may be a clinically useful imaging modality for early detection of recurrent osteosarcoma, considering the limitations of 18 F-FDG PET in a setting of low glycolytic activity.

Clinical study on minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage.

PubMed

Liang, Ke-Shan; Ding, Jian; Yin, Cheng-Bin; Peng, Li-Jing; Liu, Zhen-Chuan; Guo, Xiao; Liang, Shu-Yu; Zhang, Yong; Zhou, Sheng-Nian

2017-12-04

This study aims to compare the curative effect of different treatment methods of hypertensive putamen hemorrhage, in order to determine an ideal method of treatment; and to explore the curative effect of the application of soft channel technology-minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage. Patients with hypertensive cerebral hemorrhage, who were treated in our hospital from January 2015 to January 2016, were included into this study. Patients were divided into three groups: minimally invasive drainage group, internal medical treatment group and craniotomy group. In the minimally invasive drainage group, puncture aspiration and drainage were performed according to different hematoma conditions detected in brain CT, the frontal approach was selected for putamen and intracerebral hemorrhage, and drainage was reserved until the hematoma disappeared in CT detection. Drug therapy was dominated in the internal medical treatment group, while surgery under general anesthesia was performed to remove the hematoma in the craniotomy group. Post-treatment neurological function defect scores in minimally invasive drainage group and internal medical group were 16.14 ± 11.27 and 31.43 ± 10.42, respectively; and the difference was remarkably significant (P< 0.01). Post-treatment neurological function defect scores in the minimally invasive drainage group and craniotomy group were 16.14 ± 11.27 and 24.20 ± 12.23, respectively; and the difference was statistically significant (P< 0.05). There was a remarkable significant difference in ADL1-2 level during followed-up in survival patients between the minimally invasive drainage group and internal medical treatment group (P< 0.01), and there was a significant difference in followed-up mortality between these two groups (P< 0.01). Clinical observation and following-up results revealed that minimally invasive drainage treatment was superior to internal medical treatment and craniotomy.

Frontal sinuses and head-butting in goats: a finite element analysis.

PubMed

Farke, Andrew A

2008-10-01

Frontal sinuses in goats and other mammals have been hypothesized to function as shock absorbers, protecting the brain from blows during intraspecific combat. Furthermore, sinuses are thought to form through removal of ;structurally unnecessary' bone. These hypotheses were tested using finite element modeling. Three-dimensional models of domesticated goat (Capra hircus) skulls were constructed, with variable frontal bone and frontal sinus morphology, and loaded to simulate various head-butting behaviors. In general, models with sinuses experienced higher strain energy values (a proxy for shock absorption) than did models with unvaulted frontal bones, and the latter often had higher magnitudes than models with solid vaulted frontal bones. Furthermore, vaulted frontal bones did not reduce magnitudes of principal strain on the surface of the endocranial cavity relative to models with unvaulted frontal bones under most loading conditions. Thus, these results were only partially consistent with sinuses, or the bone that walls the sinuses, acting as shock absorbers. It is hypothesized that the keratinous horn sheaths and cranial sutures are probably more important for absorbing blows to the head. Models with sinuses did exhibit a more ;efficient' distribution of stresses, as visualized by histograms in which models with solid frontal bones had numerous unloaded elements. This is consistent with the hypothesis that sinuses result at least in part from the removal of mechanically unnecessary bone.

Atlas and feature based 3D pathway visualization enhancement for skull base pre-operative fast planning from head CT

NASA Astrophysics Data System (ADS)

Aghdasi, Nava; Li, Yangming; Berens, Angelique; Moe, Kris S.; Bly, Randall A.; Hannaford, Blake

2015-03-01

Minimally invasive neuroendoscopic surgery provides an alternative to open craniotomy for many skull base lesions. These techniques provides a great benefit to the patient through shorter ICU stays, decreased post-operative pain and quicker return to baseline function. However, density of critical neurovascular structures at the skull base makes planning for these procedures highly complex. Furthermore, additional surgical portals are often used to improve visualization and instrument access, which adds to the complexity of pre-operative planning. Surgical approach planning is currently limited and typically involves review of 2D axial, coronal, and sagittal CT and MRI images. In addition, skull base surgeons manually change the visualization effect to review all possible approaches to the target lesion and achieve an optimal surgical plan. This cumbersome process relies heavily on surgeon experience and it does not allow for 3D visualization. In this paper, we describe a rapid pre-operative planning system for skull base surgery using the following two novel concepts: importance-based highlight and mobile portal. With this innovation, critical areas in the 3D CT model are highlighted based on segmentation results. Mobile portals allow surgeons to review multiple potential entry portals in real-time with improved visualization of critical structures located inside the pathway. To achieve this we used the following methods: (1) novel bone-only atlases were manually generated, (2) orbits and the center of the skull serve as features to quickly pre-align the patient's scan with the atlas, (3) deformable registration technique was used for fine alignment, (4) surgical importance was assigned to each voxel according to a surgical dictionary, and (5) pre-defined transfer function was applied to the processed data to highlight important structures. The proposed idea was fully implemented as independent planning software and additional data are used for verification and validation. The experimental results show: (1) the proposed methods provided greatly improved planning efficiency while optimal surgical plans were successfully achieved, (2) the proposed methods successfully highlighted important structures and facilitated planning, (3) the proposed methods require shorter processing time than classical segmentation algorithms, and (4) these methods can be used to improve surgical safety for surgical robots.

Scalp and skull influence on near infrared photon propagation in the Colin27 brain template.

PubMed

Strangman, Gary E; Zhang, Quan; Li, Zhi

2014-01-15

Near-infrared neuromonitoring (NIN) is based on near-infrared spectroscopy (NIRS) measurements performed through the intact scalp and skull. Despite the important effects of overlying tissue layers on the measurement of brain hemodynamics, the influence of scalp and skull on NIN sensitivity are not well characterized. Using 3555 Monte Carlo simulations, we estimated the sensitivity of individual continuous-wave NIRS measurements to brain activity over the entire adult human head by introducing a small absorption perturbation to brain gray matter and quantifying the influence of scalp and skull thickness on this sensitivity. After segmenting the Colin27 template into five tissue types (scalp, skull, cerebrospinal fluid, gray matter and white matter), the average scalp thickness was 6.9 ± 3.6 mm (range: 3.6-11.2mm), while the average skull thickness was 6.0 ± 1.9 mm (range: 2.5-10.5mm). Mean NIN sensitivity - defined as the partial path length through gray matter divided by the total photon path length - ranged from 0.06 (i.e., 6% of total path length) at a 20mm source-detector separation, to over 0.19 at 50mm separations. NIN sensitivity varied substantially around the head, with occipital pole exhibiting the highest NIRS sensitivity to gray matter, whereas inferior frontal regions had the lowest sensitivity. Increased scalp and skull thickness were strongly associated with decreased sensitivity to brain tissue. Scalp thickness always exhibited a slightly larger effect on sensitivity than skull thickness, but the effect of both varied with SD separation. We quantitatively characterize sensitivity around the head as well as the effects of scalp and skull, which can be used to interpret NIN brain activation studies as well as guide the design, development and optimization of NIRS devices and sensors. Copyright © 2013 Elsevier Inc. All rights reserved.

Treatise on skull fractures by Berengario da Carpi (1460-1530).

PubMed

Mazzola, Riccardo F; Mazzola, Isabella C

2009-11-01

Jacopo Berengario was born in Carpi, a medieval city close to Modena (northern Italy), circa 1460. He studied medicine at Bologna University and, in 1489, graduated in philosophy and medicine. He was appointed lecturer in anatomy and surgery at the same university, a position that he maintained for 24 years. Between 1514 and 1523, Berengario published some important anatomic and surgical works, which gave considerable fame to him.Commentaria... supra Anatomiam Mundini (Commentary... on the Anatomy of Mondino), published in 1521, constitutes the first example of an illustrated anatomic textbook ever printed. The anatomic illustrations were intended for explaining the text. Artistically speaking, the plates are typical examples of the Renaissance period and worthy of the greatest consideration.De Fractura Calvae sive Cranei (On Fracture of the Calvaria or Cranium), published in Bologna in 1518, is the first treatise devoted to head injuries ever printed. It is a landmark in the development of cranial surgery that went through numerous editions. The text was prepared in 2 months and dedicated to Lorenzo de' Medici, Duke of Urbino, who experienced a skull injury in the occipital region. Berengario wanted to demonstrate to other physicians his knowledge of anatomy and his expertise on the brain and head traumas. The book includes the illustration of an entire surgical kit or a corpus instrumentorum for performing cranial operations, which appeared for the first time in a printed book. However, Berengario's highly commendable aim was to indicate to the reader the step-by-step procedure of craniotomy for management of skull fractures along with the sequential use of the previously presented instruments.

Supraorbital Keyhole Craniotomy for Basilar Artery Aneurysms: Accounting for the "Cliff" Effect.

PubMed

Stamates, Melissa M; Wong, Andrew K; Bhansali, Anita; Wong, Ricky H

2017-04-01

Treatment of basilar artery aneurysms is challenging. While endovascular techniques have dominated, there still remain circumstances where open surgical clipping is required or preferred. Minimally invasive "keyhole" approaches are being used more frequently to provide the durability of surgical clipping with a lower morbidity profile; however, careful patient selection is required. The supraorbital "keyhole" approach has been described for the treatment of basilar artery aneurysms, but careful assessment of the basilar exposure is necessary to ensure proper visualization of the aneurysm and ability to obtain proximal vascular control. Various methods of estimating the basilar artery exposure in this approach have been described, including the anterior skull base line and the posterior clinoid line, but both are unreliable and inaccurate. To propose a new method, the orbital roof-dorsum line, to simply and accurately predict the basilar artery exposure. CT angiograms for 20 consecutive unique patients were analyzed to obtain the anterior skull base line, posterior clinoid line, and the orbital roof-dorsum line. CT angiograms were then loaded onto a Stealth neuronavigation system (Medtronic, Minneapolis, Minnesota) to obtain "true" visualization lengths. A case illustration is presented. Pairwise comparison tests demonstrated that both the anterior skull base and the posterior clinoid estimation lines differed significantly from the "true"  value ( P < .0001). Our orbital roof-dorsum estimation provided results that accurately predicted the "true" value ( P = .71). The orbital roof-dorsum line provides a simple and reliable method of estimating basilar artery exposure and should be used whenever considering patients for surgical clipping by this approach. Copyright © 2017 by the Congress of Neurological Surgeons

A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors.

PubMed

Graffeo, Christopher S; Dietrich, August R; Grobelny, Bartosz; Zhang, Meng; Goldberg, Judith D; Golfinos, John G; Lebowitz, Richard; Kleinberg, David; Placantonakis, Dimitris G

2014-08-01

Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations.

A stereotaxic atlas of the forebrain of the bank vole (Clethrionomys glareolus).

PubMed

Vandebroek, I; Bouche, K; D'Herde, K; Caemaert, J; Roels, F; Odberg, F O

1999-04-01

In this article part of the forebrain of the bank vole (Clethrionomys glareolus) is presented in stereotaxic coordinates. The stereotaxic procedure was performed as follows. With the vole's head mounted in a stereotaxic adaptor, internal reference tracks were made with a 0.5-mm diameter microdialysis cannula and India ink, 2 mm in front and 2.6 mm behind the skull landmark bregma. Brains were fixed for 72 h in 4% commercial formaldehyde in sodiumcacodylate buffer containing 1% CaCl2. To determine shrinkage they were weighed before and after fixation. After embedding in paraffin they were sectioned at 25 microm and stained with Nissl. Photomicrographs were taken from the brain of one animal while its frontal (antero-posterior) coordinates of five neural structures were compared with those of 12 other voles. Variability was also checked in lateral and vertical directions at frontal level -1.0 mm (relative to bregma). The results show that the distance between the two skull landmarks bregma and lambda correlates significantly and negatively with the antero-posterior position of each of the brain areas. On the basis of these results an equation is proposed to improve accuracy in locating neural structures that deviate due to biological variability.

Augmented reality-assisted bypass surgery: embracing minimal invasiveness.

PubMed

Cabrilo, Ivan; Schaller, Karl; Bijlenga, Philippe

2015-04-01

The overlay of virtual images on the surgical field, defined as augmented reality, has been used for image guidance during various neurosurgical procedures. Although this technology could conceivably address certain inherent problems of extracranial-to-intracranial bypass procedures, this potential has not been explored to date. We evaluate the usefulness of an augmented reality-based setup, which could help in harvesting donor vessels through their precise localization in real-time, in performing tailored craniotomies, and in identifying preoperatively selected recipient vessels for the purpose of anastomosis. Our method was applied to 3 patients with Moya-Moya disease who underwent superficial temporal artery-to-middle cerebral artery anastomoses and 1 patient who underwent an occipital artery-to-posteroinferior cerebellar artery bypass because of a dissecting aneurysm of the vertebral artery. Patients' heads, skulls, and extracranial and intracranial vessels were segmented preoperatively from 3-dimensional image data sets (3-dimensional digital subtraction angiography, angio-magnetic resonance imaging, angio-computed tomography), and injected intraoperatively into the operating microscope's eyepiece for image guidance. In each case, the described setup helped in precisely localizing donor and recipient vessels and in tailoring craniotomies to the injected images. The presented system based on augmented reality can optimize the workflow of extracranial-to-intracranial bypass procedures by providing essential anatomical information, entirely integrated to the surgical field, and help to perform minimally invasive procedures. Copyright © 2015 Elsevier Inc. All rights reserved.

Innovative real CSF leak simulation model for rhinology training: human cadaveric design.

PubMed

AlQahtani, Abdulaziz A; Albathi, Abeer A; Alhammad, Othman M; Alrabie, Abdulkarim S

2018-04-01

To study the feasibility of designing a human cadaveric simulation model of real CSF leak for rhinology training. The laboratory investigation took place at the surgical academic center of Prince Sultan Military Medical City between 2016 and 2017. Five heads of human cadaveric specimens were cannulated into the intradural space through two frontal bone holes. Fluorescein-dyed fluid was injected intracranialy, then endoscopic endonasal iatrogenic skull base defect was created with observation of fluid leak, followed by skull base reconstruction. The outcome measures included subjective assessment of integrity of the design, the ability of creating real CSF leak in multiple site of skull base and the possibility of watertight closure by various surgical techniques. The fluid filled the intradural space in all specimens without spontaneous leak from skull base or extra sinus areas. Successfully, we demonstrated fluid leak from all areas after iatrogenic defect in the cribriform plate, fovea ethmoidalis, planum sphenoidale sellar and clival regions. Watertight closure was achieved in all defects using different reconstruction techniques (overly, underlay and gasket seal closure). The design is simulating the real patient with CSF leak. It has potential in the learning process of acquiring and maintaining the surgical skills of skull base reconstruction before direct involvement of the patient. This model needs further evaluation and competence measurement as training tools in rhinology training.

Non-traumatic spontaneous acute epidural hematoma in a patient with sickle cell disease.

PubMed

Serarslan, Yurdal; Aras, Mustafa; Altaş, Murat; Kaya, Hasan; Urfalı, Boran

2014-01-01

A 19-year-old female with sickle cell anemia (SCD) was referred to our hospital after two days of hospitalization at another hospital for a headache crisis. This headache crisis was due to a raised intracranial pressure; these symptoms were noted and included in her comprehensive list of symptoms. There was an acute drop in the hemoglobin and hematocrit levels. The cranial CT scan demonstrated a left fronto-parietal acute epidural hematoma (AEH) and a calvarial bone expansion, which was suggestive of medullary hematopoiesis. The patient underwent emergent craniotomy and evacuation of the hematoma. There were no abnormal findings intra-operatively apart from the AEH, except skull thickening and active petechial bleeding from the dural arteries. Repeated CT scan showed a complete evacuation of the hematoma. The possible underlying pathophysiological mechanisms were discussed. In addition to the factors mentioned in the relevant literature, any active petechial bleeding from the dural arteries on the separated surface of the dura from the skull could have contributed to the expanding of the AEH in our patient. Neurosurgeons and other health care providers should be aware of spontaneous AEH in patients with SCD. Copyright © 2013 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Autologous cranial bone graft use for trepanation reconstruction.

PubMed

Worm, Paulo Valdeci; Ferreira, Nelson Pires; Finger, Guilherme; Collares, Marcus Vinicius Martins

2015-11-01

Esthetic deformities in the human skull are a subject of concern among neurosurgical patients and neurosurgeons; they can be disfiguring and harm the patient's social relationships. To access inner structures, neurosurgical operations require skull trepanation, a process that frequently involves loss of bone tissue and leads to esthetic problems. Satisfactory reconstruction is a challenge, and neurosurgeons search for an implant which ideally is organic and low cost and does not cause an immunological or allergic reaction. Therefore, autologous bone tissue remains the gold standard for reconstruction. To develop a technique that allows neurosurgeons to rebuild the trepanation hole with a better esthetic outcome. Craniotomy orifices in 108 patients were closed with a graft obtained from the cranial bone inner layer. In order to remove the graft a specially made trephine was used. No grafts dislocated during follow-up. Cosmetic outcomes and results seen on image examinations were favorable for this new technique when compared with others previously described in medical literature. The authors present a new and feasible trepanation reconstruction technique that allows a better esthetic outcome without increasing the surgical risk for the patient, or making the surgical procedure longer or more expensive. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Olfactory groove meningiomas.

PubMed

Hentschel, Stephen J; DeMonte, Franco

2003-06-15

Olfactory groove meningiomas (OGMs) arise over the cribriform plate and may reach very large sizes prior to presentation. They can be differentiated from tuberculum sellae meningiomas because OGMs arise more anterior in the skull base and displace the optic nerve and chiasm inferiorly rather than superiorly. The authors searched the neurosurgery database at the M. D. Anderson Cancer Center for cases of OGM treated between 1993 and 2003. The records of these patients were then reviewed retrospectively for details regarding clinical presentation, imaging findings, surgical results and complications, and follow-up status. Thirteen patients, (12 women and one man, mean age 56 years) harbored OGMs (mean size 5.7 cm). All patients underwent bifrontal craniotomies and biorbital osteotomies. There were 11 complete resections (including the hyperostotic bone and dura of the cribriform plate and any extension into the ethmoid sinuses) and two subtotal resections with minimal residual tumor left in patients with recurrent lesions. No complication directly due to the surgery occurred in any patient. There were no recurrences in a mean follow-up period of 2 years (range 0-5 years). With current microsurgical techniques, the results of OGM resection are excellent, with a high rate of total resection and a low incidence of complications. All hyperostotic bone should be removed with the dura of the anterior skull base to minimize the risk of recurrence.

Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report.

PubMed

Liu, J T; Tyan, Y S; Lee, Y K; Wang, J T

2006-03-01

Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3-5 days. CT scans were performed daily from days 1 to 5. In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8-12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.

Salvage of infected craniotomy bone flaps with the wash-in, wash-out indwelling antibiotic irrigation system. Technical note and case series of 12 patients.

PubMed

Auguste, Kurtis I; McDermott, Michael W

2006-10-01

When complicated by infection, craniotomy bone flaps are commonly removed, discarded, and delayed cranioplasty is performed. This treatment paradigm is costly, carries the risks associated with additional surgery, and may cause cosmetic deformities. The authors present their experience with an indwelling antibiotic irrigation system used for the sterilization and salvage of infected bone flaps as an alternative to their removal and replacement. The authors retrospectively reviewed the medical records for 12 patients with bone flap infections following craniotomy who received treatment with the wash-in, wash-out indwelling antibiotic irrigation system. Infected flaps were removed and scrubbed with povidone-iodine solution and soaked in 1.5% hydrogen peroxide while the wound was debrided. The bone flaps were returned to the skull and the irrigation system was installed. Antibiotic medication was infused through the system for a mean of 5 days. Intravenous antibiotic therapy was continued for 2 weeks and oral antibiotics for 3 months postoperatively. Wound checks were performed at clinic follow-up visits, and there was a mean follow-up period of 13 months. Eleven of the 12 patients who had undergone placement of the bone flap irrigation system experienced complete resolution of the infection. In five patients there was involvement of the nasal sinus cavities, and in four there was a history of radiation treatment. In the one patient whose infection recurred, there was both involvement of the nasal sinuses and a history of extensive radiation treatment. Infected bone flaps can be salvaged, thus avoiding the cost, risk, and possible disfigurement associated with flap removal and delayed cranioplasty. Although prior radiation treatment and involvement of the nasal sinuses may interfere with wound healing and clearance of the infection, these factors should not preclude the use of irrigation with antibiotic agents for bone flap salvage.

Statistical shape modelling to aid surgical planning: associations between surgical parameters and head shapes following spring-assisted cranioplasty.

PubMed

Rodriguez-Florez, Naiara; Bruse, Jan L; Borghi, Alessandro; Vercruysse, Herman; Ong, Juling; James, Greg; Pennec, Xavier; Dunaway, David J; Jeelani, N U Owase; Schievano, Silvia

2017-10-01

Spring-assisted cranioplasty is performed to correct the long and narrow head shape of children with sagittal synostosis. Such corrective surgery involves osteotomies and the placement of spring-like distractors, which gradually expand to widen the skull until removal about 4 months later. Due to its dynamic nature, associations between surgical parameters and post-operative 3D head shape features are difficult to comprehend. The current study aimed at applying population-based statistical shape modelling to gain insight into how the choice of surgical parameters such as craniotomy size and spring positioning affects post-surgical head shape. Twenty consecutive patients with sagittal synostosis who underwent spring-assisted cranioplasty at Great Ormond Street Hospital for Children (London, UK) were prospectively recruited. Using a nonparametric statistical modelling technique based on mathematical currents, a 3D head shape template was computed from surface head scans of sagittal patients after spring removal. Partial least squares (PLS) regression was employed to quantify and visualise trends of localised head shape changes associated with the surgical parameters recorded during spring insertion: anterior-posterior and lateral craniotomy dimensions, anterior spring position and distance between anterior and posterior springs. Bivariate correlations between surgical parameters and corresponding PLS shape vectors demonstrated that anterior-posterior (Pearson's [Formula: see text]) and lateral craniotomy dimensions (Spearman's [Formula: see text]), as well as the position of the anterior spring ([Formula: see text]) and the distance between both springs ([Formula: see text]) on average had significant effects on head shapes at the time of spring removal. Such effects were visualised on 3D models. Population-based analysis of 3D post-operative medical images via computational statistical modelling tools allowed for detection of novel associations between surgical parameters and head shape features achieved following spring-assisted cranioplasty. The techniques described here could be extended to other cranio-maxillofacial procedures in order to assess post-operative outcomes and ultimately facilitate surgical decision making.

Intracranial Foreign Body in a Patient With Paranoid Schizophrenia.

PubMed

Andereggen, Lukas; Biétry, Damien; Kottke, Raimund; Andres, Robert H

2017-10-01

Self-inflicted penetrating head injuries in patients with paranoid schizophrenia are an infrequent phenomenon. The authors report on a psychiatric patient who presented with epistaxis. Computed tomography showed a nail passing from the nasal cavity into the frontal lobe. Given the proximity to large intracranial vessels, a craniotomy was performed and the nail was retracted. The patient later reported having hammered the nail into the nasal cavity with the intention to "kill the voice in my head." Despite use of the latest imaging modalities, metal artifacts may have limited the assessment of vascular involvement. Surgical decision-making preventing secondary damage is crucial in them.

Recurrent unilateral headache associated with SAPHO syndrome.

PubMed

Tsugawa, Jun; Ouma, Shinji; Fukae, Jiro; Tsuboi, Yoshio

2014-01-01

A 57-year-old woman was admitted with recurrent episodes of right frontal headache. Head magnetic resonance imaging (MRI) revealed extensive thickening and enhancement of the right frontal dura, muscle and fascia, as well as abnormal signal intensity and enhancement of bone marrow at the lesions. Synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome was diagnosed based on the patient's 8-year history of treatment of palmoplantar pustulosis and abnormal accumulations in the right temporal, sternum, and left medial clavicula on bone scintigraphy. SAPHO syndrome may be associated with skull lesions, which can contribute to the onset of repeated headache or dural thickening, thus these symptoms should be recognized as manifestations of this syndrome.

Intraosseous hemangioma of the clivus: a case report and review of the literature.

PubMed

Moravan, M J; Petraglia, A L; Almast, J; Yeaney, G A; Miller, M C; Edward Vates, G

2012-09-01

Intraosseous hemangiomas are benign vascular tumors that are encountered most commonly in vertebrae and rarely in the skull. When presenting in the skull, they are commonly found in the calvarium in frontal and parietal bones and seldom in the skull base. We encountered a patient with an incidental finding on magnetic resonance imaging (MRI) of an enhancing lesion in the clivus. Here we report an unusual location of a clival intraosseous hemangioma. A 62 year old man worked up for carpal tunnel syndrome had imaging of his cervical spine that revealed an enhancing clival lesion, which extended into the left occipital condyle. Endoscopic endonasal biopsy was performed on the abnormality revealing a capillary hemangioma. Patient tolerated the biopsy well and no further surgical intervention is indicated at this time. Patient will be followed at six month intervals. Primary intraosseus hemangiomas of the skull are extremely rare and usually occur in the calvarium. This is one of the few reported case of an intraosseus hemangioma in the clivus. We present this case in part because it is unusual, but more importantly, with the wider use of MRI, it is likely that these lesions will be discovered more frequently, and conceivably confused for more dangerous lesions.

Imaging and Outcomes for a New Entity: Low-Grade Sinonasal Sarcoma with Neural and Myogenic Features.

PubMed

Cannon, Richard B; Wiggins, Richard H; Witt, Benjamin L; Dundar, Yusuf; Johnston, Tawni M; Hunt, Jason P

2017-01-01

Objectives  Low-grade sinonasal sarcoma with neural and myogenic features (LGSSNMF) is a new, rare tumor. Our goal is to describe the imaging characteristics and surgical outcomes of this unique skull base malignancy. Design  Retrospective case series. Setting  Academic medical center. Participants  There were three patients who met inclusion criteria with a confirmed LGSSNMF. Main Outcome Measures  Imaging and histopathological characteristics, treatments, survival and recurrence outcomes, complications, morbidity, and mortality. Results  Patients presented with diplopia, facial discomfort, a supraorbital mass, and nasal obstruction. Magnetic resonance imaging and computed tomography imaging in all cases showed an enhancing sinonasal mass with associated hyperostotic bone formation that involved the frontal sinus, invaded the lamina papyracea and anterior skull base, and had intracranial extension. One patient underwent a purely endoscopic surgical resection and the second underwent a craniofacial resection, while the last is pending treatment. All patients recovered well, without morbidity or long-term complications, and are currently without evidence of disease (mean follow-up of 2.1 years). One patient recurred after 17 months and underwent a repeat endoscopic skull base and dural resection. Conclusions  The surgical outcomes and imaging of this unique, locally aggressive skull base tumor are characterized.

A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors

PubMed Central

Graffeo, Christopher S.; Dietrich, August R.; Grobelny, Bartosz; Zhang, Meng; Goldberg, Judith D.; Golfinos, John G.; Lebowitz, Richard; Kleinberg, David; Placantonakis, Dimitris G.

2014-01-01

Endoscopic endonasal surgery has been established as the safest approach to pituitary tumors, yet its role in other common skull base lesions has not been established. To answer this question, we carried out a systematic review of reported series of open and endoscopic endonasal approaches to four major skull base tumors: olfactory groove meningiomas (OGM), tuberculum sellae meningiomas (TSM), craniopharyngiomas (CRA), and clival chordomas (CHO). Data from 162 studies containing 5,701 patients were combined and compared for differences in perioperative mortality, gross total resection (GTR), cerebrospinal fluid (CSF) leak, neurological morbidity, post-operative visual function, post-operative anosmia, post-operative diabetes insipidus (DI), and post-operative obesity/hyperphagia. Weighted average rates for each outcome were calculated using relative study size. Our findings indicate similar rates of GTR and perioperative mortality between open and endoscopic approaches for all tumor types. CSF leak was increased after endoscopic surgery. Visual function symptoms were more likely to improve after endoscopic surgery for TSM, CRA, and CHO. Post-operative DI and obesity/hyperphagia were significantly increased after open resection in CRA. Recurrence rates per 1,000 patient-years of follow-up were higher in endoscopy for OGM, TSM, and CHO. Trends for open and endoscopic surgery suggested modest improvement in all outcomes over time. Our observations suggest that endonasal endoscopy is a safe alternative to craniotomy and may be preferred for certain tumor types. However, endoscopic surgery is associated with higher rates of CSF leak, and possibly increased recurrence rates. Prospective study with long-term follow-up is required to verify these preliminary observations. PMID:24014055

Spring-assisted posterior skull expansion without osteotomies.

PubMed

Arnaud, Eric; Marchac, Alexandre; Jeblaoui, Yassine; Renier, Dominique; Di Rocco, Federico

2012-09-01

A posterior flatness of the skull vault can be observed in infants with brachycephaly. Such posterior deformation favours the development of turricephaly which is difficult to correct. To reduce the risk of such deformation, an early posterior skull remodelling has been suggested. Translambdoid springs can be used to allow for a distraction through the patent lambdoid sutures and obtain a progressive increase of the posterior skull volume. The procedure consists in a posterior scalp elevation, the patient being on a prone position. Springs made of stainless steel wire (1.5 mm in diameter) are bent in a U-type fashion, and strategically positioned across both lambdoid sutures. No drilling is usually necessary, as the lambdoid suture can be gently forced with a subperiosteal elevator in its middle and an indentation can be created with a bony rongeur on each side of the open suture to allow for a self-retention of bayonet-shaped extremity of the spring. Careful attention is addressed to the favoured prone position during the post-operative period. After a delay of 3-6 months, the springs can be removed during a second uneventful procedure, with limited incisions, usually as a preliminary step of the subsequent frontal remodelling. The concept of spring-assisted expansion across patent sutures under 6 months of age was confirmed in our experience (19 cases). Insertion of the springs allowed for immediate distraction across the suture. A posterior remodelling of the skull could be achieved with minimal morbidity allowing to delay safely a radical anterior surgery.

Sinus septi nasi: Anatomical study.

PubMed

Mladina, Ranko; Antunović, Romano; Cingi, Cemal; Bayar Muluk, Nuray; Skitarelić, Neven

2017-04-01

The aim of this study was to perform a pioneering investigation into the incidence of pneumatization in human skulls. A total of 93 human skulls (≥20 years of age, 69 males, 24 females) were included in the study. The skulls were scanned in a fixed position using cone beam computed tomography (CBCT). The pneumatized space parameters within the nasal septum-width, length, and height-were measured. Two types of finding were identified: (a) Pneumatization, named "sinus septi nasi" (SSN), and (b) "spongy bone" (SB). The results showed SSN in 32 of the 93 skulls (34.4%). The SSN formations were from 0.5 to 4.2 mm wide, 3.5 to 18.8 mm long, and 3.8 to 17.7 mm high. Tumefactions filled with SB were found in 61 of the 93 skulls (65.59%). These were not suitable for precise measurements since the outer borders were not strictly and well defined on CT scans (perhaps because of the preparation process). In conclusion, the perpendicular plate of the ethmoidal bone is not always compact bone; in 34.4% of cases, it shows a degree of pneumatization. In contrast, an enlarged formation filled with SB is present in 65.59% of cases. The possible sources of pneumatization of this little-investigated region are discussed: sphenoid sinus, frontal sinus, and vomeronasal organ. Clin. Anat. 30:312-317, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Preservation of cranial nerves during removal of the brain for an enhanced student experience in neuroanatomy classes.

PubMed

Long, Jennifer; Roberts, David J H; Pickering, James D

2014-01-01

Neuroanatomy teaching at the University of Leeds includes the examination of isolated brains by students working in small groups. This requires the prosected brains to exhibit all 12 pairs of cranial nerves. Traditional methods of removing the brain from the skull involve elevating the frontal lobes and cutting each cranial nerve as the brain is reflected posteriorly. This can leave a substantial length of each nerve attached to the skull base rather than to the removed brain. We have found a posterior approach more successful. In this study, five adult heads were disarticulated at the level of the thyroid cartilage and placed, prone, in a head stand. A wedge of bone from the occipital region was removed before the cerebellum and brainstem were elevated to visualize the cranial nerves associated with the medulla oblongata, cerebellopontine angle and mesencephalic-pontine junction prior to cutting them as close to the skull as possible. Five brains were successfully removed from the skull, each having a full complement of cranial nerves of good length attached to them. This approach significantly increases the length and number of cranial nerves remaining attached to the brain, which supports student education. For integration into head and neck dissection courses, careful consideration will be required to ensure the necks are suitably dissected and to decide whether the cranial nerves are best left attached to the skull base or brain. Copyright © 2013 Wiley Periodicals, Inc.

Pride diaries: sex, brain size and sociality in the African lion (Panthera leo) and cougar (Puma concolor).

PubMed

Arsznov, Bradley M; Sakai, Sharleen T

2012-01-01

The purpose of this study was to examine if differences in social life histories correspond to intraspecific variation in total or regional brain volumes in the African lion (Panthera leo) and cougar (Puma concolor). African lions live in gregarious prides usually consisting of related adult females, their dependent offspring, and a coalition of immigrant males. Upon reaching maturity, male lions enter a nomadic and often, solitary phase in their lives, whereas females are mainly philopatric and highly social throughout their lives. In contrast, the social life history does not differ between male and female cougars; both are solitary. Three-dimensional virtual endocasts were created using computed tomography from the skulls of 14 adult African lions (8 male, 6 female) and 14 cougars (7 male, 7 female). Endocranial volume and basal skull length were highly correlated in African lions (r = 0.59, p < 0.05) and in cougars (r = 0.67, p < 0.01). Analyses of total endocranial volume relative to skull length revealed no sex differences in either African lions or cougars. However, relative anterior cerebrum volume comprised primarily of frontal cortex and surface area was significantly greater in female African lions than males, while relative posterior cerebrum volume and surface area was greater in males than females. These differences were specific to the neocortex and were not found in the solitary cougar, suggesting that social life history is linked to sex-specific neocortical patterns in these species. We further hypothesize that increased frontal cortical volume in female lions is related to the need for greater inhibitory control in the presence of a dominant male aggressor. Copyright © 2012 S. Karger AG, Basel.

The value of the identification of predisposing factors for post-traumatic amnesia in management of mild traumatic brain injury.

PubMed

Fotakopoulos, George; Makris, Demosthenes; Tsianaka, Eleni; Kotlia, Polikceni; Karakitsios, Paulos; Gatos, Charalabos; Tzannis, Alkiviadis; Fountas, Kostas

2018-01-01

To identify the risk factors for post-traumatic amnesia (PTA) and to document the incidence of PTA after mild traumatic brain injuries. This was a prospective study, affecting mild TBI (mTBI) (Glasgow Coma Scale 14-15) cases attending to the Emergency Department between January 2009 and April 2012 (40 months duration). Patients were divided into two groups (Group A: without PTA, and Group B: with PTA, and they were assessed according to the risk factors. A total of 1762 patients (males: 1002, 56.8%) were meeting study inclusion criteria [Group A: n = 1678 (83.8%), Group B: n = 84 (4.2%)]. Age, CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs, and skull base fractures), anticoagulation therapy and seizures were independent factors of PTA. There was no statistically significant correlation between PTA and sex, convexity fractures, stroke event, mechanism of mTBI (fall +/or beating), hypertension, coronary heart disease, chronic smokers and diabetes (p > 0.005). CT findings: (traumatic focal HCs in the frontal and temporal lobes or more diffuse punctate HCs and skull base fractures), age, seizures and anticoagulation/antiplatelet therapy, were independent factors of PTA and could be used as predictive factors after mTBI.

Preliminary Investigation of Skull Fracture Patterns Using an Impactor Representative of Helmet Back-Face Deformation.

PubMed

Weisenbach, Charles A; Logsdon, Katie; Salzar, Robert S; Chancey, Valeta Carol; Brozoski, Fredrick

2018-03-01

Military combat helmets protect the wearer from a variety of battlefield threats, including projectiles. Helmet back-face deformation (BFD) is the result of the helmet defeating a projectile and deforming inward. Back-face deformation can result in localized blunt impacts to the head. A method was developed to investigate skull injury due to BFD behind-armor blunt trauma. A representative impactor was designed from the BFD profiles of modern combat helmets subjected to ballistic impacts. Three post-mortem human subject head specimens were each impacted using the representative impactor at three anatomical regions (frontal bone, right/left temporo-parietal regions) using a pneumatic projectile launcher. Thirty-six impacts were conducted at energy levels between 5 J and 25 J. Fractures were detected in two specimens. Two of the specimens experienced temporo-parietal fractures while the third specimen experienced no fractures. Biomechanical metrics, including impactor acceleration, were obtained for all tests. The work presented herein describes initial research utilizing a test method enabling the collection of dynamic exposure and biomechanical response data for the skull at the BFD-head interface.

Awake Craniotomy with Noninvasive Brain Mapping by 3-Tesla Functional Magnetic Resonance Imaging for Excision of Low-grade Glioma: A Case of a Young Patient from Pakistan.

PubMed

Aleem Bhatti, Atta Ul; Jakhrani, Nasir Khan; Parekh, Maria Adnan

2018-01-01

The past few years have seen increasing support for gross total resection in the management of low-grade gliomas (LGGs), with a greater extent of resection correlated with better overall survival, progression-free survival, and time to malignant transformation. There is consistent evidence in literature supporting extent of safe resection as a good prognostic indicator as well as positively affecting seizure control, symptomatic relief in pressure symptoms, and longer progression-free and total survival. The operative goal in most LGG cases is to maximize the extent of resection for these benefits while avoiding postoperative neurologic deficits. Several advanced invasive and noninvasive surgical techniques such as intraoperative magnetic resonance imaging (MRI), fluorescence-guided surgery, intraoperative functional pathway mapping, and neuronavigation have been developed in an attempt to better achieve maximal safe resection. We present a case of LGG in a young patient with a 5-year history of refractory seizures and gradual onset walking difficulty. Serial MRI brain scans revealed a progressive increase in right frontal tumor size with substantial edema and parafalcine herniation. Noninvasive brain mapping by functional MRI (fMRI) and sleep-awake-sleep type of anesthesia with endotracheal tube insertion was utilized during an awake craniotomy. Histopathology confirmed a Grade II oligodendroglioma, and genetic analysis revealed no codeletion at 1p/19q. Neurological improvement was remarkable in terms of immediate motor improvement, and the patient remained completely seizure free on a single antiepileptic drug. There is no radiologic or clinical evidence of recurrence 6 months postoperatively. This is the first published report of an awake craniotomy for LGG in Pakistan. The contemporary concept of supratotal resection in LGGs advocates generous functional resection even beyond MRI findings rather than mere excision of oncological boundaries. This relatively aggressive approach is only possible with an awake craniotomy, which ensures preservation of functional status and thus less postoperative morbidity and better outcomes. Noninvasive mapping for intracranial space-occupying lesions, including fMRI and blood-oxygen-level dependent (BOLD) imaging modality, is an essential tool in a resource-limited setting such as Pakistan.

Management of advanced intracranial intradural juvenile nasopharyngeal angiofibroma: combined single-stage rhinosurgical and neurosurgical approach.

PubMed

Naraghi, Mohsen; Saberi, Hooshang; Mirmohseni, Atefeh Sadat; Nikdad, Mohammad Sadegh; Afarideh, Mohsen

2015-07-01

Although intracranial extension of juvenile nasopharyngeal angiofibroma (JNA) occurs commonly, intradural penetration is extremely rare. Management of such tumors is a challenging issue in skull-base surgery, necessitating their removal via combined approaches. In this work, we share our experience in management of extensive intradural JNA. In a university hospital-based setting of 2 tertiary care academic centers, retrospective chart of 6 male patients (5 between 15 and 19 years old) was reviewed. Patients presented chiefly with nasal obstruction, epistaxis, and proptosis. One of them was an aggressive recurrent tumor in a 32-year-old patient. All cases underwent combined transnasal, transmaxillary, and craniotomy approaches assisted by the use of image-guided endoscopic surgery, with craniotomy preceding the rhinosurgical approach in 3 cases. Adding a transcranial approach to the transnasal and transmaxillary endoscopic approaches provided 2-sided exposure and appreciated access to the huge intradural JNAs. One postoperative cerebrospinal fluid leak and 1 postoperative recurrence at the site of infratemporal fossa were treated successfully. Otherwise, the course was uneventful in the remaining cases. Management of intracranial intradural JNA requires a multidisciplinary approach of combined open and endoscopic-assisted rhinosurgery and neurosurgery, because of greater risk for complications during the dissection. Carotid rupture and brain damage remain 2 catastrophic complications that should always be kept in mind. A combined rhinosurgical and neurosurgical approach also has the advantage of very modest cosmetic complications. © 2015 ARS-AAOA, LLC.

Langerhans cell histiocytosis of skull: a retrospective study of 18 cases.

PubMed

Zhang, Xiang-Heng; Zhang, Ji; Chen, Zheng-He; Sai, Ke; Chen, Yin-Sheng; Wang, Jian; Ke, Chao; Guo, Chen-Chen; Chen, Zhong-Ping; Mou, Yong-Gao

2017-04-01

The present study presents 18 cases of Chinese patients harboring a Langerhans cell histiocytosis (LCH) of the skull. Eighteen consecutive patients were diagnosed as LCH of the skull and confirmed pathologically between March 2002 and February 2014. In the present study, the patients of LCH without skull involvement were excluded. According to disease extent at diagnosis, the 18 LCH patients with skull involvement were divided into three groups: (I) unifocal-monosystem group, including ten cases with solitary skull lesion; (II) multifocal-monosystem group, including two cases with multiple bone lesions and no extra-skeletal involvement; (III) multisystem group, including six cases with LCH lesions involving both skeletal and extra-skeletal system. In unifocal-monosystem group, excision of the skull lesion was performed in eight of ten cases, a low dosage of local radiotherapy and a purposeful observation was accept by the remaining two cases of this group after biopsy respectively. In multifocal-monosystem group, both of the two cases were received chemotherapy. In multi-system group, all the six cases were managed with systemic chemotherapy, after their diagnoses of LCH were confirmed. The mean age at the time of diagnosis was 9.4 years. There was a male predominance in this disease male/female ratio was 3.5:1. In our cases, a skull mass with or without tenderness was the most common chief complaint (13 cases, 72.2%), and frontal bone was the most frequent affected locations of skull (6 cases, 33.3%). In unifocal-monosystem group, nine of ten remained free from LCH, the remain one lesion recurred 22 months after his surgical excision. In multifocal-monosystem group, a complete response (CR) was obtained in one of them, and a stable disease (SD) of multiple osseous lesions was obtained in another one. In the multi-system group, a CR in four cases and a partial response (PR) in one case were obtained, and a progressive disease (PD) was observed in the remaining one. The unifocal-monosystem of LCH of the skull is a clinicopathological entity with a good outcome, and resection, irradiation or purposeful observation are also can be been utilized as the choice of treatment. For the multifocal bone lesions and multisystem lesions of LCH, chemotherapy is an effective treatment as a systemic therapy. There is no enough publication literature to determine guidelines or indications for managing this disease.

30 Years of Neurosurgical Robots: Review and Trends for Manipulators and Associated Navigational Systems.

PubMed

Smith, James Andrew; Jivraj, Jamil; Wong, Ronnie; Yang, Victor

2016-04-01

This review provides an examination of contemporary neurosurgical robots and the developments that led to them. Improvements in localization, microsurgery and minimally invasive surgery have made robotic neurosurgery viable, as seen by the success of platforms such as the CyberKnife and neuromate. Neurosurgical robots can now perform specific surgical tasks such as skull-base drilling and craniotomies, as well as pedicle screw and cochlear electrode insertions. Growth trends in neurosurgical robotics are likely to continue but may be tempered by concerns over recent surgical robot recalls, commercially-driven surgeon training, and studies that show operational costs for surgical robotic procedures are often higher than traditional surgical methods. We point out that addressing performance issues related to navigation-related registration is an active area of research and will aid in improving overall robot neurosurgery performance and associated costs.

Endoscopic transpterygoidal repair of a large cranial defect with cerebrospinal fluid leak in a patient with extensive osteoradionecrosis of the skull base: case report and technical note.

PubMed

Brand, Y; Lim, E; Waran, V; Prepageran, N

2015-12-01

Endoscopic endonasal techniques have recently become the method of choice in dealing with cerebrospinal fluid leak involving the anterior cranial fossa. However, most surgeons prefer an intracranial approach when leaks involve the middle cranial fossa. This case report illustrates the possibilities of using endoscopic techniques for cerebrospinal fluid leaks involving the middle fossa. A 37-year-old male patient presented with multiple areas of cranial defect with cerebrospinal fluid leak due to osteoradionecrosis following radiation for nasopharyngeal carcinoma 4 years earlier. Clinical examination showed involvement of all cranial nerves except the IInd and XIth nerves on the left side. A prior attempt to repair the cerebrospinal fluid leak with craniotomy was not successful. This case demonstrates the successful endoscopic repair of a large cranial defect with cerebrospinal fluid leak.

Development and human factors analysis of neuronavigation vs. augmented reality.

PubMed

Pandya, Abhilash; Siadat, Mohammad-Reza; Auner, Greg; Kalash, Mohammad; Ellis, R Darin

2004-01-01

This paper is focused on the human factors analysis comparing a standard neuronavigation system with an augmented reality system. We use a passive articulated arm (Microscribe, Immersion technology) to track a calibrated end-effector mounted video camera. In real time, we superimpose the live video view with the synchronized graphical view of CT-derived segmented object(s) of interest within a phantom skull. Using the same robotic arm, we have developed a neuronavigation system able to show the end-effector of the arm on orthogonal CT scans. Both the AR and the neuronavigation systems have been shown to be within 3mm of accuracy. A human factors study was conducted in which subjects were asked to draw craniotomies and answer questions to gage their understanding of the phantom objects. The human factors study included 21 subjects and indicated that the subjects performed faster, with more accuracy and less errors using the Augmented Reality interface.

Comprehensive approach to image-guided surgery

NASA Astrophysics Data System (ADS)

Peters, Terence M.; Comeau, Roch M.; Kasrai, Reza; St. Jean, Philippe; Clonda, Diego; Sinasac, M.; Audette, Michel A.; Fenster, Aaron

1998-06-01

Image-guided surgery has evolved over the past 15 years from stereotactic planning, where the surgeon planned approaches to intracranial targets on the basis of 2D images presented on a simple workstation, to the use of sophisticated multi- modality 3D image integration in the operating room, with guidance being provided by mechanically, optically or electro-magnetically tracked probes or microscopes. In addition, sophisticated procedures such as thalamotomies and pallidotomies to relieve the symptoms of Parkinson's disease, are performed with the aid of volumetric atlases integrated with the 3D image data. Operations that are performed stereotactically, that is to say via a small burr- hole in the skull, are able to assume that the information contained in the pre-operative imaging study, accurately represents the brain morphology during the surgical procedure. On the other hand, preforming a procedure via an open craniotomy presents a problem. Not only does tissue shift when the operation begins, even the act of opening the skull can cause significant shift of the brain tissue due to the relief of intra-cranial pressure, or the effect of drugs. Means of tracking and correcting such shifts from an important part of the work in the field of image-guided surgery today. One approach has ben through the development of intra-operative MRI imaging systems. We describe an alternative approach which integrates intra-operative ultrasound with pre-operative MRI to track such changes in tissue morphology.

Association of contact loading in diffuse axonal injuries from motor vehicle crashes.

PubMed

Yoganandan, Narayan; Gennarelli, Thomas A; Zhang, Jiangyue; Pintar, Frank A; Takhounts, Erik; Ridella, Stephen A

2009-02-01

Although studies have been conducted to analyze brain injuries from motor vehicle crashes, the association of head contact has not been fully established. This study examined the association in occupants sustaining diffuse axonal injuries (DAIs). The 1997 to 2006 motor vehicle Crash Injury Research Engineering Network database was used. All crash modes and all changes in velocity were included; ejections and rollovers were excluded; injuries to front and rear seat occupants with and without restraint use were considered. DAI were coded in the database using Abbreviated Injury Scale 1990. Loss of consciousness was included and head contact was based on medical- and crash-related data. Sixty-seven occupants with varying ages were coded with DAI. Forty-one adult occupants (mean, 33 years of age, 171-cm tall, 71-kg weight; 30 drivers, 11 passengers) were analyzed. Mean change in velocity was 41.2 km/h and Glasgow Coma Scale score was 4. There were 33 lateral, 6 frontal, and 2 rear crashes with 32 survivors and 9 were fatalities. Two occupants in the same crash did not sustain DAI. Although skull fractures and scalp injuries occurred in some impacts, head contact was identified in all frontal, rear, and far side, and all but one nearside crashes. Using a large sample size of occupants sustaining DAI in 1991 to 2006 model year vehicles, DAI occurred more frequently in side than frontal crashes, is most commonly associated with impact load transfer, and is not always accompanied by skull fractures. The association of head contact in >95% of cases underscores the importance of evaluating crash-related variables and medical information for trauma analysis. It would be prudent to include contact loading in addition to angular kinematics in the analysis and characterization of DAI.

Evolution of skull shape in the family Salamandridae (Amphibia: Caudata).

PubMed

Ivanović, Ana; Arntzen, Jan W

2018-03-01

We carried out a comparative morphometric analysis of 56 species of salamandrid salamanders, representing 19 out of 21 extant genera, with the aim of uncovering the major patterns of skull shape diversification, and revealing possible trends and directions of evolutionary change. To do this we used micro-computed tomography scanning and three-dimensional geometric morphometrics, along with a well-resolved molecular phylogeny. We found that allometry explains a relatively small amount of shape variation across taxa. Congeneric species of salamandrid salamanders are more similar to each other and cluster together producing distinct groups in morphospace. We detected a strong phylogenetic signal and little homoplasy. The most pronounced changes in the skull shape are related to the changes of the frontosquamosal arch, a unique feature of the cranial skeleton for the family Salamandridae, which is formed by processes arising from the frontal and squamosal bones that arch over the orbits. By mapping character states over the phylogeny, we found that a reduction of the frontosquamosal arch occurs independently in three lineages of the subfamily Pleurodelinae. This reduction can probably be attributed to changes in the development and ossification rates of the frontosquamosal arch. In general, our results are similar to those obtained for caecilian amphibians, with an early expansion into the available morphospace and a complex history characterizing evolution of skull shape in both groups. To evaluate the specificity of the inferred evolutionary trajectories and Caudata-wide trends in the diversity of skull morphology, information from additional groups of tailed amphibians is needed. © 2017 Anatomical Society.

Treatment of anterior skull base defects by a transnasal endoscopic approach in children.

PubMed

Di Rocco, Federico; Couloigner, Vincent; Dastoli, Patricia; Sainte-Rose, Christian; Zerah, Michel; Roger, Gilles

2010-11-01

The object of this study was to assess the efficacy and complications of endoscopic management of anterior skull base defects. The authors reviewed the medical records of 28 children (20 boys and 8 girls) undergoing endoscopic repair of anterior skull base defects in their tertiary referral center between 2001 and 2008; 18 cases were congenital and 10 cases posttraumatic. During the endoscopic procedure, rigid telescopes--2.7 or 4 mm in diameter, with 0° or 30° lenses--were used. In 23 patients the anterior skull base defect was sealed with fragments of middle turbinate (bone and mucosa). In the remaining 5 patients it was sealed with cartilage harvested from the nasal septum (3 cases) or from the auricle (2 cases), fibrin glue, and oxidized cellulose. A combined external and endoscopic approach was required in 3 cases because of the size and extensions of the encephalocele. Outcome was primarily assessed by means of clinical examination, nasal fibroscopy, and imaging. The mean duration of follow-up was 26.7 months (range 9-57 months). One patient treated by a combined approach died of meningitis 2 years after surgery. In the remaining 27 patients, there was no recurrence of CSF leak, meningitis, or encephalocele. An iatrogenic frontal or ethmoidal mucocele was observed in 4 cases. The endoscopic approach is a minimally invasive, safe, and efficient technique for removing nasal encephaloceles in children.

An optimal set of landmarks for metopic craniosynostosis diagnosis from shape analysis of pediatric CT scans of the head

NASA Astrophysics Data System (ADS)

Mendoza, Carlos S.; Safdar, Nabile; Myers, Emmarie; Kittisarapong, Tanakorn; Rogers, Gary F.; Linguraru, Marius George

2013-02-01

Craniosynostosis (premature fusion of skull sutures) is a severe condition present in one of every 2000 newborns. Metopic craniosynostosis, accounting for 20-27% of cases, is diagnosed qualitatively in terms of skull shape abnormality, a subjective call of the surgeon. In this paper we introduce a new quantitative diagnostic feature for metopic craniosynostosis derived optimally from shape analysis of CT scans of the skull. We built a robust shape analysis pipeline that is capable of obtaining local shape differences in comparison to normal anatomy. Spatial normalization using 7-degree-of-freedom registration of the base of the skull is followed by a novel bone labeling strategy based on graph-cuts according to labeling priors. The statistical shape model built from 94 normal subjects allows matching a patient's anatomy to its most similar normal subject. Subsequently, the computation of local malformations from a normal subject allows characterization of the points of maximum malformation on each of the frontal bones adjacent to the metopic suture, and on the suture itself. Our results show that the malformations at these locations vary significantly (p<0.001) between abnormal/normal subjects and that an accurate diagnosis can be achieved using linear regression from these automatic measurements with an area under the curve for the receiver operating characteristic of 0.97.

Chapter 1: Sinonasal anatomy and function.

PubMed

Dalgorf, Dustin M; Harvey, Richard J

2013-01-01

An understanding of paranasal sinus anatomy based on important fixed landmarks rather than variable anatomy is critical to ensure safe and complete surgery. The concept of the paranasal surgical box defines the anatomic limits of dissection. The boundaries of the surgical box include the middle turbinate medially, orbital wall laterally, and skull base superiorly. The "vertical component" of the surgical box defines the boundaries of the frontal recess and includes the middle turbinate and intersinus septum medially, medial orbital wall and orbital roof laterally, nasofrontal beak anteriorly, and skull base and posterior table of frontal sinus posteriorly. The paranasal sinuses are divided into anterior, posterior, and sphenoidal functional cavities based on their distinct drainage pathways into the nose. The ultimate goal of surgery is to create a functional sinus cavity. Application of the paranasal surgical box and its vertical component enables the surgeon to view the limits of dissection with a single position of the endoscope. This will ensure complete dissection of the functional sinonasal compartments and effectively avoid leaving behind disconnected cells from the surgical cavity, mucocele formation, mucous recirculation, overcome obstructive phenomenon and enable maximal delivery of topical therapy in the post-operative setting. This article reviews the structure and function of the nasal cartilages and turbinates. It also describes the concept of the paranasal surgical box, key anatomical landmarks and limits of dissection. Normal anatomy and common variants of normal anatomy are discussed.

A microcontroller-based simulation of dural venous sinus injury for neurosurgical training.

PubMed

Cleary, Daniel R; Siler, Dominic A; Whitney, Nathaniel; Selden, Nathan R

2018-05-01

OBJECTIVE Surgical simulation has the potential to supplement and enhance traditional resident training. However, the high cost of equipment and limited number of available scenarios have inhibited wider integration of simulation in neurosurgical education. In this study the authors provide initial validation of a novel, low-cost simulation platform that recreates the stress of surgery using a combination of hands-on, model-based, and computer elements. Trainee skill was quantified using multiple time and performance measures. The simulation was initially validated using trainees at the start of their intern year. METHODS The simulation recreates intraoperative superior sagittal sinus injury complicated by air embolism. The simulator model consists of 2 components: a reusable base and a disposable craniotomy pack. The simulator software is flexible and modular to allow adjustments in difficulty or the creation of entirely new clinical scenarios. The reusable simulator base incorporates a powerful microcomputer and multiple sensors and actuators to provide continuous feedback to the software controller, which in turn adjusts both the screen output and physical elements of the model. The disposable craniotomy pack incorporates 3D-printed sections of model skull and brain, as well as artificial dura that incorporates a model sagittal sinus. RESULTS Twelve participants at the 2015 Western Region Society of Neurological Surgeons postgraduate year 1 resident course ("boot camp") provided informed consent and enrolled in a study testing the prototype device. Each trainee was required to successfully create a bilateral parasagittal craniotomy, repair a dural sinus tear, and recognize and correct an air embolus. Participant stress was measured using a heart rate wrist monitor. After participation, each resident completed a 13-question categorical survey. CONCLUSIONS All trainee participants experienced tachycardia during the simulation, although the point in the simulation at which they experienced tachycardia varied. Survey results indicated that participants agreed the simulation was realistic, created stress, and was a useful tool in training neurosurgical residents. This simulator represents a novel, low-cost approach for hands-on training that effectively teaches and tests residents without risk of patient injury.

Surgery for juvenile nasopharyngeal angiofibroma with lateral extension to the infratemporal fossa.

PubMed

Yamada, Masato; Tsunoda, Atsunobu; Tokumaru, Takao; Aoyagi, Masaru; Kawano, Yoshihisa; Yano, Tomoyuki; Kishimoto, Seiji

2014-08-01

The study aimed to assess the usefulness of skull base surgery for large juvenile nasopharyngeal angiofibroma (JNA) with lateral extension to the infratemporal fossa. Eleven cases were enrolled for this study, and the mean age was 17.7 years old (range: 8-32). Six out of 11 cases underwent surgery as an initial treatment, and the other five underwent secondary surgery after initial surgery or radiotherapy in other institutions. The range of extension of tumor, feeding arteries, surgical approach, and treatment outcome were estimated. All tumors originated from the sphenopalatine foramen. Based on the imaging study, there was extension to the cavernous sinus observed in eight cases, as well as to the middle cranial fossa (8), orbit (4), and anterior cranial fossa (1). These tumors were diagnosed as Andrews' Stage IVa (3) and IVb (8). However, infiltration into the cavernous sinus was observed in one case only during surgery. Ten tumors were separated carefully from the cavernous sinus or dura and were accurately diagnosed as Stage IIIb. In all cases, the main arterial feeders of the JNAs were branches of the external carotid artery, which were embolized prior to surgery. However, 10 cases were also fed by branches of the internal carotid artery (branches of the ophthalmic artery), in which these arteries could not be embolized. Coronal skin incision (1) and a facial dismasking flap (9) were used, and in one case, wide lateral skin incision with temporary incision of the facial nerve was applied. The orbito-zygomatic approach and its modification was applied to all the cases. Fronto-lateral craniotomy was applied in four cases and lateral craniotomy in seven cases. Total resection was achieved in 10 cases and subtotal resection in one case. No mortality was noted in this series. Temporal trismus was observed in all cases which subsided gradually. Cheek numbness and facial palsy were observed in three and two cases, respectively. Coupled with craniotomy, tumor removal was successfully carried out in 11 patients with JNAs, which showed large lateral extension. Our surgical strategy is a safe and effective approach for the removal of JNAs with infratemporal fossa extension. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Combination radiotherapy in an orthotopic mouse brain tumor model.

PubMed

Kramp, Tamalee R; Camphausen, Kevin

2012-03-06

Glioblastoma multiforme (GBM) are the most common and aggressive adult primary brain tumors. In recent years there has been substantial progress in the understanding of the mechanics of tumor invasion, and direct intracerebral inoculation of tumor provides the opportunity of observing the invasive process in a physiologically appropriate environment. As far as human brain tumors are concerned, the orthotopic models currently available are established either by stereotaxic injection of cell suspensions or implantation of a solid piece of tumor through a complicated craniotomy procedure. In our technique we harvest cells from tissue culture to create a cell suspension used to implant directly into the brain. The duration of the surgery is approximately 30 minutes, and as the mouse needs to be in a constant surgical plane, an injectable anesthetic is used. The mouse is placed in a stereotaxic jig made by Stoetling (figure 1). After the surgical area is cleaned and prepared, an incision is made; and the bregma is located to determine the location of the craniotomy. The location of the craniotomy is 2 mm to the right and 1 mm rostral to the bregma. The depth is 3 mm from the surface of the skull, and cells are injected at a rate of 2 μl every 2 minutes. The skin is sutured with 5-0 PDS, and the mouse is allowed to wake up on a heating pad. From our experience, depending on the cell line, treatment can take place from 7-10 days after surgery. Drug delivery is dependent on the drug composition. For radiation treatment the mice are anesthetized, and put into a custom made jig. Lead covers the mouse's body and exposes only the brain of the mouse. The study of tumorigenesis and the evaluation of new therapies for GBM require accurate and reproducible brain tumor animal models. Thus we use this orthotopic brain model to study the interaction of the microenvironment of the brain and the tumor, to test the effectiveness of different therapeutic agents with and without radiation.

Hyperostosis frontalis interna: criteria for sexing and aging a skeleton.

PubMed

May, Hila; Peled, Nathan; Dar, Gali; Cohen, Haim; Abbas, Janan; Medlej, Bahaa; Hershkovitz, Israel

2011-09-01

Estimation of sex and age in skeletons is essential in anthropological and forensic medicine investigations. The aim of the current study was to examine the potential of hyperostosis frontalis interna (HFI) as a criterion for determining sex and age in forensic cases. Macroscopic examination of the inner aspect of the frontal bone of 768 skulls (326 males and 442 females) aged 1 to 103, which had undergone a head computerized tomography scan, was carried out using the volume rendering technique. HFI was divided into two categories: minor and major. HFI is a sex- and age-dependent phenomena, with females manifesting significantly higher prevalence than males (p<0.01). In both females and males, prevalence of HFI increases as age increases (p<0.01). We present herein the probabilities of designating an unknown skull to a specific sex and age cohort according to the presence of HFI (standardized to age distribution in an Israeli population). Moreover, we present the probability of an individual belonging to a specific sex or age cohort according to age or sex (respectively) and severity of HFI. We suggest a valid, reliable, and easy method for sex and age identification of unknown skulls.

Pathologies in the extinct Pleistocene Eurasian steppe lion Panthera leo spelaea ()-Results of fights with hyenas, bears and lions and other ecological stresses.

PubMed

Rothschild, Bruce M; Diedrich, Cajus G

2012-12-01

Late Pleistocene Eurasian steppe lions Panthera leo spelaea (Goldfuss, 1810) frequently (3 of 13) have skull damage attributable to bites. Such evidence is found only in lions from hyena or cave bear dens. Wounds on frontal and parietal bones appear to be the result of battles during cave bear hunts, by antagonistic conflicts with hyenas, and less often from fights with conspecifics. Skull bite damage is extremely rare in modern lions, suggesting that this Eurasian lion pathology is the result of inter-specific (with cave bears) rather than intra-specific conflicts. The sex specificity of maxillary porosity (found only in lions among modern felidae) is also documented in its close genetic relation, P. l. spelaea. The pattern of skeletal exostotic reaction reveals them to have been pursuit rather than ambush predators. Copyright © 2012 Elsevier Inc. All rights reserved.

Computed tomography assessment of peripubertal craniofacial morphology in a sheep model of binge alcohol drinking in the first trimester

PubMed Central

Birch, Sharla M.; Lenox, Mark W.; Kornegay, Joe N.; Shen, Li; Ai, Huisi; Ren, Xiaowei; Goodlett, Charles R.; Cudd, Tim A.; Washburn, Shannon E.

2015-01-01

Identification of facial dysmorphology is essential for the diagnosis of fetal alcohol syndrome (FAS); however, most children with fetal alcohol spectrum disorders (FASD) do not meet the dysmorphology criterion. Additional objective indicators are needed to help identify the broader spectrum of children affected by prenatal alcohol exposure. Computed tomography (CT) was used in a sheep model of prenatal binge alcohol exposure to test the hypothesis that quantitative measures of craniofacial bone volumes and linear distances could identify alcohol-exposed lambs. Pregnant sheep were randomly assigned to four groups: heavy binge alcohol, 2.5 g/kg/day (HBA); binge alcohol, 1.75 g/kg/day (BA); saline control (SC); and normal control (NC). Intravenous alcohol (BA; HBA) or saline (SC) infusions were given three consecutive days per week from gestation day 4–41, and a CT scan was performed on postnatal day 182. The volumes of eight skull bones, cranial circumference, and 19 linear measures of the face and skull were compared among treatment groups. Lambs from both alcohol groups showed significant reduction in seven of the eight skull bones and total skull bone volume, as well as cranial circumference. Alcohol exposure also decreased four of the 19 craniofacial measures. Discriminant analysis showed that alcohol-exposed and control lambs could be classified with high accuracy based on total skull bone volume, frontal, parietal, or mandibular bone volumes, cranial circumference, or interorbital distance. Total skull volume was significantly more sensitive than cranial circumference in identifying the alcohol-exposed lambs when alcohol-exposed lambs were classified using the typical FAS diagnostic cutoff of ≤10th percentile. This first demonstration of the usefulness of CT-derived craniofacial measures in a sheep model of FASD following binge-like alcohol exposure during the first trimester suggests that volumetric measurement of cranial bones may be a novel biomarker for binge alcohol exposure during the first trimester to help identify non-dysmorphic children with FASD. PMID:26496796

Can orbital angle morphology distinguish dogs from wolves?

PubMed

Janssens, Luc; Spanoghe, Inge; Miller, Rebecca; Van Dongen, Stefan

For more than a century, the orbital angle has been studied by many authors to distinguish dog skulls from their progenitor, the wolf. In early studies, the angle was reported to be different between dogs (49°-55°) and wolves (39°-46°). This clear difference was, however, questioned in a more recent Scandinavian study that shows some overlap. It is clear that in all studies several methodological issues were unexplored or unclear and that group sizes and the variety of breeds and wolf subspecies were small. Archaeological dog skulls had also not been studied. Our goal was to test larger and more varied groups and add archaeological samples as they are an evolutionary stage between wolves and modern dogs. We also tested the influence of measuring methods, intra- and inter-reliability, angle symmetry, the influence of variations in skull position and the possibility of measuring and comparing this angle on 3D CT scan images. Our results indicate that there is about 50 % overlap between the angle range in wolves and modern dogs. However, skulls with a very narrow orbital angle were only found in wolves and those with a very wide angle only in dogs. Archaeological dogs have a mean angle very close to the one of the wolves. Symmetry is highest in wolves and lowest in archaeological dogs. The measuring method is very reliable, for both inter- and intra-reliability (0.99-0.97), and most skull position changes have no statistical influence on the angle measured. Three-dimensional CT scan images can be used to measure OA, but the angles differ from direct measuring and cannot be used for comparison. Evolutionary changes in dog skulls responsible for the wider OA compared to wolf skulls are mainly the lateralisation of the zygomatic process of the frontal bone. Our conclusion is that the orbital angle can be used as an additional morphological measuring method to discern wolves from recent and archaeological dogs. Angles above 60° are certainly from recent dogs. Angles under 35° are certainly of wolves.

Late-onset en coup de sabre of the skull.

PubMed

Mohan, Shaun V; Nittur, Vinay; Stevens, Kathryn J

2013-10-01

En coup de sabre is a rare subtype of linear scleroderma that characteristically affects the skin, underlying muscle, and bone of the frontoparietal region of the face and scalp. It typically presents in the first two decades of life, and may be associated with focal neurological deficits. We present a case of late-onset en coup de sabre of the frontal bone where the diagnosis was further complicated by a history of breast cancer, prior trauma to the region, and use of topical medication.

Intraoperative language localization in multilingual patients with gliomas.

PubMed

Bello, Lorenzo; Acerbi, Francesco; Giussani, Carlo; Baratta, Pietro; Taccone, Paolo; Songa, Valeria; Fava, Marica; Stocchetti, Nino; Papagno, Costanza; Gaini, Sergio M

2006-07-01

Intraoperative localization of speech is problematic in patients who are fluent in different languages. Previous studies have generated various results depending on the series of patients studied, the type of language, and the sensitivity of the tasks applied. It is not clear whether languages are mediated by multiple and separate cortical areas or shared by common areas. Globally considered, previous studies recommended performing a multiple intraoperative mapping for all the languages in which the patient is fluent. The aim of this work was to study the feasibility of performing an intraoperative multiple language mapping in a group of multilingual patients with a glioma undergoing awake craniotomy for tumor removal and to describe the intraoperative cortical and subcortical findings in the area of craniotomy, with the final goal to maximally preserve patients' functional language. Seven late, highly proficient multilingual patients with a left frontal glioma were submitted preoperatively to a battery of tests to evaluate oral language production, comprehension, and repetition. Each language was tested serially starting from the first acquired language. Items that were correctly named during these tests were used to build personalized blocks to be used intraoperatively. Language mapping was undertaken during awake craniotomies by the use of an Ojemann cortical stimulator during counting and oral naming tasks. Subcortical stimulation by using the same current threshold was applied during tumor resection, in a back and forth fashion, and the same tests. Cortical sites essential for oral naming were found in 87.5% of patients, those for the first acquired language in one to four sites, those for the other languages in one to three sites. Sites for each language were distinct and separate. Number and location of sites were not predictable, being randomly and widely distributed in the cortex around or less frequently over the tumor area. Subcortical stimulations found tracts for the first acquired language in four patients and for the other languages in three patients. Three of these patients decreased their fluency immediately after surgery, affecting the first acquired language, which fully recovered in two patients and partially in one. The procedure was agile and well tolerated by the patients. These findings show that multiple cortical and subcortical language mapping during awake craniotomy for tumor removal is a feasible procedure. They support the concept that intraoperative mapping should be performed for all the languages in which the patient is fluent in to preserve functional integrity.

Sex determination of a Tunisian population by CT scan analysis of the skull.

PubMed

Zaafrane, Malek; Ben Khelil, Mehdi; Naccache, Ines; Ezzedine, Ekbel; Savall, Frédéric; Telmon, Norbert; Mnif, Najla; Hamdoun, Moncef

2018-05-01

It is widely accepted that the estimation of biological attributes in the human skeleton is more accurate when population-specific standards are applied. With the shortage of such data for contemporary North African populations, it is duly required to establish population-specific standards. We present here the first craniometric standards for sex determination of a contemporary Tunisian population. The aim of this study was to analyze the correlation between sex and metric parameters of the skull in this population using CT scan analysis and to generate proper reliable standards for sex determination of a complete or fragmented skull. The study sample comprised cranial multislice computed tomography scans of 510 individuals equally distributed by sex. ASIR TM software in a General Electric TM workstation was used to position 37 landmarks along the volume-rendered images and the multiplanar slices, defining 27 inter-landmark distances. Frontal and parietal bone thickness was also measured for each case. The data were analyzed using basic descriptive statistics and logistic regression with cross-validation of classification results. All of the measurements were sexually dimorphic with male values being higher than female values. A nine-variable model achieved the maximum classification accuracy of 90% with -2.9% sex bias and a six-variable model yielded 85.9% sexing accuracy with -0.97% sex bias. We conclude that the skull is highly dimorphic and represents a reliable bone for sex determination in contemporary Tunisian individuals.

Deep brain two-photon NIR fluorescence imaging for study of Alzheimer's disease

NASA Astrophysics Data System (ADS)

Chen, Congping; Liang, Zhuoyi; Zhou, Biao; Ip, Nancy Y.; Qu, Jianan Y.

2018-02-01

Amyloid depositions in the brain represent the characteristic hallmarks of Alzheimer's disease (AD) pathology. The abnormal accumulation of extracellular amyloid-beta (Aβ) and resulting toxic amyloid plaques are considered to be responsible for the clinical deficits including cognitive decline and memory loss. In vivo two-photon fluorescence imaging of amyloid plaques in live AD mouse model through a chronic imaging window (thinned skull or craniotomy) provides a mean to greatly facilitate the study of the pathological mechanism of AD owing to its high spatial resolution and long-term continuous monitoring. However, the imaging depth for amyloid plaques is largely limited to upper cortical layers due to the short-wavelength fluorescence emission of commonly used amyloid probes. In this work, we reported that CRANAD-3, a near-infrared (NIR) probe for amyloid species with excitation wavelength at 900 nm and emission wavelength around 650 nm, has great advantages over conventionally used probes and is well suited for twophoton deep imaging of amyloid plaques in AD mouse brain. Compared with a commonly used MeO-X04 probe, the imaging depth of CRANAD-3 is largely extended for open skull cranial window. Furthermore, by using two-photon excited fluorescence spectroscopic imaging, we characterized the intrinsic fluorescence of the "aging pigment" lipofuscin in vivo, which has distinct spectra from CRANAD-3 labeled plaques. This study reveals the unique potential of NIR probes for in vivo, high-resolution and deep imaging of brain amyloid in Alzheimer's disease.

Apert Syndrome: Molecularly Confirmed C.758C>G (P.Pro253Arg) in FGFR2

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cha Gon, Lee, E-mail: leechagon@eulji.ac.kr

A 5-day-old girl was referred to our clinic for evaluation of congenital malformations. She was identified with a pathogenic mutation c.758C>G (p.Pro253Arg) in FGFR2 gene using targeted exome sequencing. The de novo mutation was confirmed with Sanger sequencing in the patient and her parents. She showed occipital plagiocephaly with frontal bossing (Figure A and B). Skull frontal and lateral radiography revealed fusion of most of the sutures except coronal suture, with convolutional markings (Figure D and E). She had complete cleft palate (Figure C). Her fused bilateral hands showed type II syndactyly with complete syndactyly between the ring and themore » little fingers (Figure F1-F3). Both toes were simple syndactyly with side-to-side fusion of skin (Figure G1-)« less

Median Supraorbital Keyhole Approach for Clipping Ruptured Distal Anterior Cerebral Artery Aneurysm: Technical Report with Review of Literature.

PubMed

Dhandapani, Sivashanmugam; Sahoo, Sushant Kumar

2018-04-01

The minimally invasive approach to distal anterior cerebral artery (DACA) aneurysms has not gained much acceptance due to difficulties associated with the conventional frontal paramedian approach. The more proximal basal interhemispheric approach, however, necessitates extensive dissection of soft tissues. We describe a novel minimally invasive median supraorbital keyhole craniotomy with a basal interhemispheric approach for clipping a ruptured DACA aneurysm. A 62-year-old patient presented with subarachnoid hemorrhage. Computed tomography angiography revealed a DACA aneurysm. The surgical technique involved a keyhole craniotomy made via an eyebrow incision extending between the supraorbital notches, and flush with the anterior cranial fossa. The dura was opened at the anterior part, the falx was cut, an interhemispheric dissection was carried out, adequate proximal control was obtained, and the aneurysm neck was dissected and clipped. A relevant review of the literature was carried out. The patient recovered well, with no residual aneurysm or forehead numbness, with good cosmesis. Compared with the previously described "keyhole unilateral interhemispheric" approaches, our technique has less likelihood of encountering bridging veins; easier cisternal cerebrospinal fluid release, making it feasible even in swollen brain; better proximal vascular control; and trajectory toward the neck rather than dome. The median supraorbital keyhole approach is a minimally invasive technique sufficient for clipping most DACA aneurysms, with easier access, better proximal control, and good cosmesis. Copyright © 2018 Elsevier Inc. All rights reserved.

Measurement of Pressure Responses in a Physical Model of a Human Head with High Shape Fidelity Based on Ct/mri Data

NASA Astrophysics Data System (ADS)

Miyazaki, Yusuke; Tachiya, Hiroshi; Anata, Kenji; Hojo, Akihiro

This study discusses a head injury mechanism in case of a human head subjected to impact, from results of impact experiments by using a physical model of a human head with high-shape fidelity. The physical model was constructed by using rapid prototyping technology from the three-dimensional CAD data, which obtained from CT/MRI images of a subject's head. As results of the experiments, positive pressure responses occurred at the impacted site, whereas negative pressure responses occurred at opposite the impacted site. Moreover, the absolute maximum value of pressure occurring at the frontal region of the intracranial space of the head model resulted in same or higher than that at the occipital site in each case that the impact force was imposed on frontal or occipital region. This result has not been showed in other study using simple shape physical models. And, the result corresponds with clinical evidences that brain contusion mainly occurs at the frontal part in each impact direction. Thus, physical model with accurate skull shape is needed to clarify the mechanism of brain contusion.

Traumatic occlusion of the anterior cerebral artery--case report.

PubMed

Ishibashi, A; Kubota, Y; Yokokura, Y; Soejima, Y; Hiratsuka, T

1995-12-01

A 71-year-old female presented with posttraumatic occlusion of the anterior cerebral artery (ACA) after a road accident in which she was hit in the mid-frontal region. Initial computed tomography (CT) demonstrated frontal skull fractures and pneumocephalus. High density areas were also identified in the right basal cisterns, suggesting traumatic subarachnoid hemorrhage. She was alert on admission, but with attendant shock due to crush wounds. Her condition rapidly deteriorated and an emergency amputation of her left leg was performed. After aggressive treatment with transfusion and infusion, her systolic pressure increased to 120 mmHg. Her consciousness remained disturbed. Serial CT disclosed hemorrhagic infarction in the entire medial side of the right frontal lobe. Magnetic resonance angiography demonstrated decreased flow voids in the bilateral A1 segments and right ACA, and a basilar artery aneurysm, which was unruptured clinically. Three weeks after the injury, she regained consciousness. Six months later, she had motor aphasia and left upper extremity weakness. The clinicopathological mechanism causing the traumatic occlusion of the ACA in the present case was probably dissecting aneurysm.

Educational utility of advanced three-dimensional virtual imaging in evaluating the anatomical configuration of the frontal recess.

PubMed

Agbetoba, Abib; Luong, Amber; Siow, Jin Keat; Senior, Brent; Callejas, Claudio; Szczygielski, Kornel; Citardi, Martin J

2017-02-01

Endoscopic sinus surgery represents a cornerstone in the professional development of otorhinolaryngology trainees. Mastery of these surgical skills requires an understanding of paranasal sinus and skull-base anatomy. The frontal sinus is associated with a wide range of variation and complex anatomical configuration, and thus represents an important challenge for all trainees performing endoscopic sinus surgery. Forty-five otorhinolaryngology trainees and 20 medical school students from 5 academic institutions were enrolled and randomized into 1 of 2 groups. Each subject underwent learning of frontal recess anatomy with both traditional 2-dimensional (2D) learning methods using a standard Digital Imaging and Communications in Medicine (DICOM) viewing software (RadiAnt Dicom Viewer Version 1.9.16) and 3-dimensional (3D) learning utilizing a novel preoperative virtual planning software (Scopis Building Blocks), with one half learning with the 2D method first and the other half learning with the 3D method first. Four questionnaires that included a total of 20 items were scored for subjects' self-assessment on knowledge of frontal recess and frontal sinus drainage pathway anatomy following each learned modality. A 2-sample Wilcoxon rank-sum test was used in the statistical analysis comparing the 2 groups. Most trainees (89%) believed that the virtual 3D planning software significantly improved their understanding of the spatial orientation of the frontal sinus drainage pathway. Incorporation of virtual 3D planning surgical software may help augment trainees' understanding and spatial orientation of the frontal recess and sinus anatomy. The potential increase in trainee proficiency and comprehension theoretically may translate to improved surgical skill and patient outcomes and in reduced surgical time. © 2016 ARS-AAOA, LLC.

Penetrating brain injury caused by nail guns: two case reports and a review of the literature.

PubMed

Luo, Wei; Liu, Hai; Hao, Shuyu; Zhang, Ying; Li, Jingsheng; Liu, Baiyun

2012-01-01

To the best of the authors' knowledge, there are few case reports of penetrating brain injuries (PBI) caused by nail guns and these have usually involved incomplete penetration of the skull. Complete penetration of a nail into the intracranial cavity is extremely rare. Here, two such cases are presented. In the first, the nail entered through the right temporal bone, lodged in the right temporal lobe and was removed via craniotomy with intra-operative ultrasound guidance. In the second, the nail destroyed the left parietal bone, damaged the left internal capsule and lodged in the left temporal lobe near the left petrous apex and the brain stem. According to the latest literature retrieval, this is the first reported case of nail-gun injury to the internal capsule. The position of the nail precluded removal without further neurologic damage. Treatment strategies designed to optimize outcome, with or without surgery, and possible complications are discussed in this report.

Analysis of the cephalometric changes in the first 3 months after spring-assisted cranioplasty for scaphocephaly.

PubMed

Ou Yang, O; Marucci, D D; Gates, R J; Rahman, M; Hunt, J; Gianoutsos, M P; Walsh, W R

2017-05-01

Spring-assisted cranioplasty (SAC) has become an accepted treatment for patients with sagittal craniosynostosis; however, the early effects of springs on skull dimensions have never been assessed with objective measurements in the literature. The present study evaluated the changes in skull dimensions and intracranial volume (ICV) during the first 3 months after SAC for sagittal synostosis. Sixteen patients with sagittal synostosis underwent SAC. The cephalic index (CI) and the distance between the spring foot plates were chronologically measured until spring removal at 3 months. Pre- and post-treatment CT scans available for 6 patients were used to assess changes in head shape. Thirteen patients underwent objective aesthetic assessment using pre- and post-operative photographs. Statistical analysis was performed using the linear mixed model for chronological data, t-test statistics for normative data comparisons and Wilcoxon's signed rank test for non-parametric data. For scaphocephalic patients, pre-operative and post-operative CIs were 0.70 and 0.74 (p = 0.001), respectively. Cranial widening towards normative values was observed (p = 0.0005). A continuous expansion in the distance between the spring foot plates was observed over the treatment period. Frontal and occipital angles were not affected by SAC despite apparent clinical improvements in frontal bossing and occipital prominence. CT analysis demonstrated relative reduction in the anterior cranial volume (p = 0.01) and relative expansion of the superior occipital volume (p = 0.03). Spring expansion was most marked in the hours following spring insertion. The expansion rate reduced to the minimum by day 1 post-operatively. Clinical benefits of SAC resulted from an increase in the bi-temporal width that camouflaged the frontal bossing. Improvement in occipital prominence was due to superior occipital volume expansion, allowing the occiput to remodel to a more rounded shape. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Inflammatory Profile of Awake Function-Controlled Craniotomy and Craniotomy under General Anesthesia

PubMed Central

Klimek, Markus; Hol, Jaap W.; Wens, Stephan; Heijmans-Antonissen, Claudia; Niehof, Sjoerd; Vincent, Arnaud J.; Klein, Jan; Zijlstra, Freek J.

2009-01-01

Background. Surgical stress triggers an inflammatory response and releases mediators into human plasma such as interleukins (ILs). Awake craniotomy and craniotomy performed under general anesthesia may be associated with different levels of stress. Our aim was to investigate whether those procedures cause different inflammatory responses. Methods. Twenty patients undergoing craniotomy under general anesthesia and 20 patients undergoing awake function-controlled craniotomy were included in this prospective, observational, two-armed study. Circulating levels of IL-6, IL-8, and IL-10 were determined pre-, peri-, and postoperatively in both patient groups. VAS scores for pain, anxiety, and stress were taken at four moments pre- and postoperatively to evaluate physical pain and mental duress. Results. Plasma IL-6 level significantly increased with time similarly in both groups. No significant plasma IL-8 and IL-10 change was observed in both experimental groups. The VAS pain score was significantly lower in the awake group compared to the anesthesia group at 12 hours postoperative. Postoperative anxiety and stress declined similarly in both groups. Conclusion. This study suggests that awake function-controlled craniotomy does not cause a significantly different inflammatory response than craniotomy performed under general anesthesia. It is also likely that function-controlled craniotomy does not cause a greater emotional challenge than tumor resection under general anesthesia. PMID:19536349

Evolution of cranial telescoping in echolocating whales (Cetacea: Odontoceti).

PubMed

Churchill, Morgan; Geisler, Jonathan H; Beatty, Brian L; Goswami, Anjali

2018-05-01

Odontocete (echolocating whale) skulls exhibit extreme posterior displacement and overlapping of facial bones, here referred to as retrograde cranial telescoping. To examine retrograde cranial telescoping across 40 million years of whale evolution, we collected 3D scans of whale skulls spanning odontocete evolution. We used a sliding semilandmark morphometric approach with Procrustes superimposition and PCA to capture and describe the morphological variation present in the facial region, followed by Ancestral Character State Reconstruction (ACSR) and evolutionary model fitting on significant components to determine how retrograde cranial telescoping evolved. The first PC score explains the majority of variation associated with telescoping and reflects the posterior migration of the external nares and premaxilla alongside expansion of the maxilla and frontal. The earliest diverging fossil odontocetes were found to exhibit a lesser degree of cranial telescoping than later diverging but contemporary whale taxa. Major shifts in PC scores and centroid size are identified at the base of Odontoceti, and early burst and punctuated equilibrium models best fit the evolution of retrograde telescoping. This indicates that the Oligocene was a period of unusually high diversity and evolution in whale skull morphology, with little subsequent evolution in telescoping. © 2018 The Author(s). Evolution © 2018 The Society for the Study of Evolution.

Identification and return of a skull from Tasmania in the Berlin anatomical collection.

PubMed

Winkelmann, Andreas; Teßmann, Barbara

2018-02-01

Following a request by the Australian government, human remains of Australian origin were identified in the anatomical collection of Charité, the medical faculty of Berlin. We initiated an interdisciplinary provenance research on such remains to ensure their identity, elucidate their history, and prepare for a possible return to Australia. Here, we present results regarding a skull in the collection labeled as stemming from Tasmania. The non-invasive anthropological investigation revealed the skull to stem from a girl of about 15 years of age who most likely died of a massive otitis/petrositis with subsequent meningitis. These results match the historical findings, which started from an inscription on the frontal bone giving a first name ("Nanny"), an ancestry ("native of Kangaroo Island"), a collector ("Schayer"), and a location ("van Diemensland", i.e. Tasmania). The collector, Adolph Schayer, was a German sheep breeder and botanical/zoological collector living in north-western Tasmania from 1831 to 1843. In archival sources, a girl named Nanny Allan could be identified, who was a native of Kangaroo Island and died in Launceston/Tasmania in 1836 at the age of about 14 years. As there were no doubts that these remains stem from a Tasmanian individual, they were handed over to representatives of the Tasmanian Aboriginal Centre in July 2014.

Taxonomic assessment of the black bear (Ursus americanus) in the eastern United States

USGS Publications Warehouse

Kennedy, M.L.; Kennedy, P.K.; Bogan, M.A.; Waits, J.L.

2002-01-01

The subspecific status of the Louisiana black bear (Ursus americanus luteolus) and Florida black bear (U. a. floridanus) were assessed using morphologic features to determine their distinctness in relation to one another and to the black bear (U. a. americanus). Forty-four dimensions were recorded from skulls of 125 male and 127 female adult (4.5 years or older) bears. Results showed skulls of U. a. luteolus, U. a. floridanus, and U. a. americanus to be similar in morphology. However, features of U. a. luteolus, and U. a. floridanus tended, in general, to be larger and shaped differently than those of U. a. americanus. Differences between measurements of U. a. luteolus and U. a. floridanus were less apparent than those between either of these taxa and U. a. americanus. For U. a. luteolus and U. a. floridanus, means of most characters differed only slightly, and ranges of all measurements overlapped to some degree. Yet, small numbers of characters that reflected molar tooth measurements or features relating to dentition, height of frontal region, and skull length and width appeared to correctly classify these taxa in most cases. Results were interpreted to support the subspecific recognition of U. a. luteolus, U. a. floridanus, and U. a. americanus.

Awake craniotomy induces fewer changes in the plasma amino acid profile than craniotomy under general anesthesia.

PubMed

Hol, Jaap W; Klimek, Markus; van der Heide-Mulder, Marieke; Stronks, Dirk; Vincent, Arnoud J; Klein, Jan; Zijlstra, Freek J; Fekkes, Durk

2009-04-01

In this prospective, observational, 2-armed study, we compared the plasma amino acid profiles of patients undergoing awake craniotomy to those undergoing craniotomy under general anesthesia. Both experimental groups were also compared with a healthy, age-matched and sex-matched reference group not undergoing surgery. It is our intention to investigate whether plasma amino acid levels provide information about physical and emotional stress, as well as pain during awake craniotomy versus craniotomy under general anesthesia. Both experimental groups received preoperative, perioperative, and postoperative dexamethasone. The plasma levels of 20 amino acids were determined preoperative, perioperative, and postoperatively in all groups and were correlated with subjective markers for pain, stress, and anxiety. In both craniotomy groups, preoperative levels of tryptophan and valine were significantly decreased whereas glutamate, alanine, and arginine were significantly increased relative to the reference group. Throughout time, tryptophan levels were significantly lower in the general anesthesia group versus the awake craniotomy group. The general anesthesia group had a significantly higher phenylalanine/tyrosine ratio, which may suggest higher oxidative stress, than the awake group throughout time. Between experimental groups, a significant increase in large neutral amino acids was found postoperatively in awake craniotomy patients, pain was also less and recovery was faster. A significant difference in mean hospitalization time was also found, with awake craniotomy patients leaving after 4.53+/-2.12 days and general anesthesia patients after 6.17+/-1.62 days; P=0.012. This study demonstrates that awake craniotomy is likely to be physically and emotionally less stressful than general anesthesia and that amino acid profiling holds promise for monitoring postoperative pain and recovery.

Brain surgery

MedlinePlus

Craniotomy; Surgery - brain; Neurosurgery; Craniectomy; Stereotactic craniotomy; Stereotactic brain biopsy; Endoscopic craniotomy ... cut depends on where the problem in the brain is located. The surgeon creates a hole in ...

Patient-specific non-linear finite element modelling for predicting soft organ deformation in real-time: application to non-rigid neuroimage registration.

PubMed

Wittek, Adam; Joldes, Grand; Couton, Mathieu; Warfield, Simon K; Miller, Karol

2010-12-01

Long computation times of non-linear (i.e. accounting for geometric and material non-linearity) biomechanical models have been regarded as one of the key factors preventing application of such models in predicting organ deformation for image-guided surgery. This contribution presents real-time patient-specific computation of the deformation field within the brain for six cases of brain shift induced by craniotomy (i.e. surgical opening of the skull) using specialised non-linear finite element procedures implemented on a graphics processing unit (GPU). In contrast to commercial finite element codes that rely on an updated Lagrangian formulation and implicit integration in time domain for steady state solutions, our procedures utilise the total Lagrangian formulation with explicit time stepping and dynamic relaxation. We used patient-specific finite element meshes consisting of hexahedral and non-locking tetrahedral elements, together with realistic material properties for the brain tissue and appropriate contact conditions at the boundaries. The loading was defined by prescribing deformations on the brain surface under the craniotomy. Application of the computed deformation fields to register (i.e. align) the preoperative and intraoperative images indicated that the models very accurately predict the intraoperative deformations within the brain. For each case, computing the brain deformation field took less than 4 s using an NVIDIA Tesla C870 GPU, which is two orders of magnitude reduction in computation time in comparison to our previous study in which the brain deformation was predicted using a commercial finite element solver executed on a personal computer. Copyright © 2010 Elsevier Ltd. All rights reserved.

Following the canyon to reach and remove olfactory groove meningiomas.

PubMed

Stefini, Roberto; Zenga, Francesco; Giacomo, Esposito; Bolzoni, Andrea; Tartara, Fulvio; Spena, Giannantonio; Ambrosi, Claudia; Fontanella, Marco M

2017-04-01

Olfactory groove meningiomas (OGMs) represent approximately 10% of all intracranial meningiomas. They arise in the olfactory fossa, a variable depression delimited by the lateral lamella and perpendicular plate. The cribriform plate with the lateral lamella and ethmoidal and orbital roof could be viewed as a 'canyon' with the frontal sinus as the main entrance. Between January 2000 and December 2013, 32 consecutive patients underwent removal of OGMs through this 'canyon' at the Department of Neurosurgery of Brescia and Turin. Complete removal was achieved in all patients with this trans-frontal sinus subcranial approach (Simpson grade I; mean lesion volume, 46.6 cm3). Five patients (15.6%) experienced nasal CSF leakage, treated with external lumbar drain positioning for 4 days and resolved in all cases but one, which was re-operated. Two patients (6.2%) during the CSF leakage experienced meningitis at day 7 after surgery, both successfully treated by intravenous antibiotic therapy. After one month, one patient developed hydrocephalus, treated with a ventricular peritoneal shunt. In one patient, traction on the OGM caused bleeding of the callosomarginal artery, which was coagulated with superior frontal gyrus ischemia without neurological consequences. Glasgow Outcome Scale Score at 6 months was V in 29 patients, IV in one patient, and I in two patients. Advantages with this approach may include easy and early control of blood supply from its insertion in the skull base, minimal frontal lobe retraction, preservation of the frontal veins draining to the sagittal sinus, and a satisfactory aesthetic outcome.

Strain in the Braincase and Its Sutures During Function

PubMed Central

Herring, Susan W.; Teng, Shengyi

2010-01-01

The skull is distinguished from other parts of the skeleton by its composite construction. The sutures between bony elements provide for interstitial growth of the cranium, but at the same time they alter the transmission of stress and strain through the skull. Strain gages were bonded to the frontal and parietal bones of miniature pigs and across the interfrontal, interparietal and coronal sutures. Strains were recorded 1) during natural mastication in conjunction with electromyographic activity from the jaw muscles and 2) during stimulation of various cranial muscles in anesthetized animals. Vault sutures exhibited vastly higher strains than did the adjoining bones. Further, bone strain primarily reflected torsion of the braincase set up by asymmetrical muscle contraction; the tensile axis alternated between +45° and −45° depending on which diagonal masseter/temporalis pair was most active. However, suture strains were not related to overall torsion but instead were responses to local muscle actions. Only the coronal suture showed significant strain (tension) during jaw opening; this was caused by the contraction of neck muscles. All sutures showed strain during jaw closing, but polarity depended on the pattern of muscle usage. For example, masseter contraction tensed the coronal suture and the anterior part of the interfrontal suture, whereas the temporalis caused compression in these locations. Peak tensile strains were larger than peak compressive strains. Histology suggested that the skull is bent at the sutures, with the ectocranial surface tensed and the endocranial surface predominantly compressed. Collectively, these results indicate that skulls with patent sutures should be analyzed as complexes of independent parts rather than solid structures. PMID:10918130

Chronic Subdural Hematoma Treated by Small or Large Craniotomy with Membranectomy as the Initial Treatment

PubMed Central

Kim, Jae-Hong; Kim, Jung-Hee; Kong, Min-Ho; Song, Kwan-Young

2011-01-01

Objective There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results. Methods Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization. Results The mean ages were 69.4±12.1 and 55.6±9.3 years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups. Conclusion Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique. PMID:22053228

Predicting sleepiness during an awake craniotomy.

PubMed

Itoi, Chihiro; Hiromitsu, Kentaro; Saito, Shoko; Yamada, Ryoji; Shinoura, Nobusada; Midorikawa, Akira

2015-12-01

An awake craniotomy is a safe neurological surgical technique that minimizes the risk of brain damage. During the course of this surgery, the patient is asked to perform motor or cognitive tasks, but some patients exhibit severe sleepiness. Thus, the present study investigated the predictive value of a patient's preoperative neuropsychological background in terms of sleepiness during an awake craniotomy. Thirty-seven patients with brain tumor who underwent awake craniotomy were included in this study. Prior to craniotomy, the patient evaluated cognitive status, and during the surgery, each patient's performance and attitude toward cognitive tasks were recorded by neuropsychologists. The present findings showed that the construction and calculation abilities of the patients were moderately correlated with their sleepiness. These results indicate that the preoperative cognitive functioning of patients was related to their sleepiness during the awake craniotomy procedure and that the patients who exhibited sleepiness during an awake craniotomy had previously experienced reduced functioning in the parietal lobe. Copyright © 2015 Elsevier B.V. All rights reserved.

Awake craniotomy for supratentorial gliomas: why, when and how?

PubMed

Ibrahim, George M; Bernstein, Mark

2012-09-01

Awake craniotomy has become an increasingly utilized procedure in the treatment of supratentorial intra-axial tumors. The popularity of this procedure is partially attributable to improvements in intraoperative technology and anesthetic techniques. The application of awake craniotomy to the field of neuro-oncology has decreased iatrogenic postoperative neurological deficits, allowed for safe maximal tumor resection and improved healthcare resource stewardship by permitting early patient discharge. In this article, we review recent evidence for the utility of awake craniotomy in the resection of gliomas and describe the senior author's experience in performing this procedure. Furthermore, we explore innovative applications of awake craniotomy to outpatient tumor resections and the conduct of neurosurgery in resource-poor settings. We conclude that awake craniotomy is an effective and versatile neurosurgical procedure with expanding applications in neuro-oncology.

Computed tomography assessment of peripubertal craniofacial morphology in a sheep model of binge alcohol drinking in the first trimester.

PubMed

Birch, Sharla M; Lenox, Mark W; Kornegay, Joe N; Shen, Li; Ai, Huisi; Ren, Xiaowei; Goodlett, Charles R; Cudd, Tim A; Washburn, Shannon E

2015-11-01

Identification of facial dysmorphology is essential for the diagnosis of fetal alcohol syndrome (FAS); however, most children with fetal alcohol spectrum disorders (FASD) do not meet the dysmorphology criterion. Additional objective indicators are needed to help identify the broader spectrum of children affected by prenatal alcohol exposure. Computed tomography (CT) was used in a sheep model of prenatal binge alcohol exposure to test the hypothesis that quantitative measures of craniofacial bone volumes and linear distances could identify alcohol-exposed lambs. Pregnant sheep were randomly assigned to four groups: heavy binge alcohol, 2.5 g/kg/day (HBA); binge alcohol, 1.75 g/kg/day (BA); saline control (SC); and normal control (NC). Intravenous alcohol (BA; HBA) or saline (SC) infusions were given three consecutive days per week from gestation day 4-41, and a CT scan was performed on postnatal day 182. The volumes of eight skull bones, cranial circumference, and 19 linear measures of the face and skull were compared among treatment groups. Lambs from both alcohol groups showed significant reduction in seven of the eight skull bones and total skull bone volume, as well as cranial circumference. Alcohol exposure also decreased four of the 19 craniofacial measures. Discriminant analysis showed that alcohol-exposed and control lambs could be classified with high accuracy based on total skull bone volume, frontal, parietal, or mandibular bone volumes, cranial circumference, or interorbital distance. Total skull volume was significantly more sensitive than cranial circumference in identifying the alcohol-exposed lambs when alcohol-exposed lambs were classified using the typical FAS diagnostic cutoff of ≤10th percentile. This first demonstration of the usefulness of CT-derived craniofacial measures in a sheep model of FASD following binge-like alcohol exposure during the first trimester suggests that volumetric measurement of cranial bones may be a novel biomarker for binge alcohol exposure during the first trimester to help identify non-dysmorphic children with FASD. Copyright © 2015 Elsevier Inc. All rights reserved.

[Awake craniotomy].

PubMed

2012-01-01

The article is a literature review on awake craniotomy. History of method, indications and contraindications, necessary conditions for successful application as well as complications and their prevention and correction are considered Outcomes in patients with neuro-oncological pathology and in patients with intractable epilepsy after awake craniotomy are also analyzed. It's also shown that awake craniotomy can make removal of tumors near eloquent cortex more radical and improve neurological outcome in such patients.

Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor.

PubMed

Nossek, Erez; Matot, Idit; Shahar, Tal; Barzilai, Ori; Rapoport, Yoni; Gonen, Tal; Sela, Gal; Korn, Akiva; Hayat, Daniel; Ram, Zvi

2013-02-01

Awake craniotomy for removal of intraaxial tumors within or adjacent to eloquent brain regions is a well-established procedure. However, awake craniotomy failures have not been well characterized. In the present study, the authors aimed to analyze and assess the incidence and causes for failed awake craniotomy. The database of awake craniotomies performed at Tel Aviv Medical Center between 2003 and 2010 was reviewed. Awake craniotomy was considered a failure if conversion to general anesthesia was required, or if adequate mapping or monitoring could not have been achieved. Of 488 patients undergoing awake craniotomy, 424 were identified as having complete medical, operative, and anesthesiology records. The awake craniotomies performed in 27 (6.4%) of these 424 patients were considered failures. The main causes of failure were lack of intraoperative communication with the patient (n = 18 [4.2%]) and/or intraoperative seizures (n = 9 [2.1%]). Preoperative mixed dysphasia (p < 0.001) and treatment with phenytoin (p = 0.0019) were related to failure due to lack of communication. History of seizures (p = 0.03) and treatment with multiple antiepileptic drugs (p = 0.0012) were found to be related to failure due to intraoperative seizures. Compared with the successful awake craniotomy group, a significantly lower rate of gross-total resection was achieved (83% vs 54%, p = 0.008), there was a higher incidence of short-term speech deterioration postoperatively (6.1% vs 23.5%, p = 0.0017) as well as at 3 months postoperatively (2.3% vs 15.4%, p = 0.0002), and the hospitalization period was longer (4.9 ± 6.2 days vs 8.0 ± 10.1 days, p < 0.001). Significantly more major complications occurred in the failure group (4 [14.8%] of 27) than in the successful group (16 [4%] of 397) (p = 0.037). Failures of awake craniotomy were associated with a lower incidence of gross-total resection and increased postoperative morbidity. The majority of awake craniotomy failures were preventable by adequate patient selection and avoiding side effects of drugs administered during surgery.

Optically measured NADH concentrations are unaffected by propofol induced EEG silence during transient cerebral hypoperfusion in anesthetized rabbits☆

PubMed Central

Wang, Mei; Agarwal, Sachin; Mayevsky, Avraham; Joshi, Shailendra

2014-01-01

The neuroprotective benefit of intra-operative anesthetics is widely described and routinely aimed to invoke electroencephalographic (EEG) silence in anticipation of transient cerebral ischemia. Previous rat survival studies have questioned an additional benefit from achieving EEG silence during transient global cerebral hypoperfusion. Surgical preparation on twelve New Zealand white rabbits under ketamine–propofol anesthesia, included placement of skull screws for bilateral EEG monitoring, skull shaving for laser Doppler probes, and a 5 mm diameter right temporal craniotomy for the NADH probe. Transient global cerebral hypoperfusion was achieved with bilateral internal carotid artery occlusion and pharmacologically induced systemic hypotension. All animals acted as controls, and had cerebral hypoperfusion under baseline propofol anesthesia with an active EEG. Thereafter, animals were randomized to receive bolus injection of intracarotid (3–5 mg) or intravenous (10–20 mg) 1% propofol to create EEG silence for 1–2 min. The data collected at baseline, peak hypoperfusion, and 5 and 10 min post hypoperfusion was analyzed by repeated measures ANOVA with post hoc Bonferroni–Dunn test. Eleven of the twelve rabbits completed the protocol. Hemodynamics and cerebral blood flow changes were comparable in all the animals. Compared to controls, the increase in NADH during ischemia was unaffected by EEG silence with either intravenous or intraarterial propofol. We failed to observe any significant additional attenuation of the elevation in NADH levels with propofol induced EEG silence during transient global cerebral hypoperfusion. This is consistent with previous rat survival studies showing that EEG silence was not required for full neuroprotective effects of pentothal anesthesia. PMID:21570061

Fourth cranial nerve: surgical anatomy in the subtemporal transtentorial approach and in the pretemporal combined inter-intradural approach through the fronto-temporo-orbito-zygomatic craniotomy. A cadaveric study.

PubMed

Pescatori, L; Niutta, M; Tropeano, M P; Santoro, G; Santoro, A

2017-01-01

Despite the recent progress in surgical technology in the last decades, the surgical treatment of skull base lesions still remains a challenge. The purpose of this study was to assess the anatomy of the tentorial and cavernous segment of the fourth cranial nerve as it appears in two different surgical approaches to the skull base: subtemporal transtentorial approach and pretemporal fronto-orbito-zygomatic approach. Four human cadaveric fixed heads were used for the dissection. Using both sides of each cadaveric head, we made 16 dissections: 8 with subtemporal transtentorial technique and 8 with pretemporal fronto-orbito-zygomatic approach. The first segment that extends from the initial point of contact of the fourth cranial nerve with the tentorium (point Q) to its point of entry into its dural channel (point D) presents an average length of 13.5 mm with an extremely wide range and varying between 3.20 and 9.3 mm. The segment 2, which extends from point D to the point of entry into the lateral wall of the cavernous sinus, presents a lesser interindividual variability (mean 10.4 mm, range 15.1-5.9 mm). A precise knowledge of the surgical anatomy of the fourth cranial nerve and its neurovascular relationships is essential to safely approach. The recognition of some anatomical landmarks allows to treat pathologies located in regions of difficult surgical access even when there is an important subversion of the anatomy.

Trans-lamina terminalis approach to third ventricle using supraorbital craniotomy: technique description and literature review for outcome comparison with anterior, lateral and trans-sphenoidal corridors.

PubMed

Krishna, V; Blaker, B; Kosnik, L; Patel, S; Vandergrift, W

2011-10-01

The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors. The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal). The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors. The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application. © Georg Thieme Verlag KG Stuttgart · New York.

Influence of bone microstructure on the mechanical properties of skull cortical bone - A combined experimental and computational approach.

PubMed

Boruah, Sourabh; Subit, Damien L; Paskoff, Glenn R; Shender, Barry S; Crandall, Jeff R; Salzar, Robert S

2017-01-01

The strength and compliance of the dense cortical layers of the human skull have been examined since the beginning of the 20th century with the wide range in the observed mechanical properties attributed to natural biological variance. Since this variance may be explained by the difference in structural arrangement of bone tissue, micro-computed tomography (µCT) was used in conjunction with mechanical testing to study the relationship between the microstructure of human skull cortical coupons and their mechanical response. Ninety-seven bone samples were machined from the cortical tables of the calvaria of ten fresh post mortem human surrogates and tested in dynamic tension until failure. A linear response between stress and strain was observed until close to failure, which occurred at 0.6% strain on average. The effective modulus of elasticity for the coupons was 12.01 ± 3.28GPa. Porosity of the test specimens, determined from µCT, could explain only 51% of the variation of their effective elastic modulus. Finite element (FE) models of the tested specimens built from µCT images indicated that modeling the microstructural arrangement of the bone, in addition to the porosity, led to a marginal improvement of the coefficient of determination to 54%. Modulus for skull cortical bone for an element size of 50µm was estimated to be 19GPa at an average. Unlike the load bearing bones of the body, almost half of the variance in the mechanical properties of cortical bone from the skull may be attributed to differences at the sub-osteon (< 50µm) level. ANOVA tests indicated that effective failure stress and strain varied significantly between the frontal and parietal bones, while the bone phase modulus was different for the superior and inferior aspects of the calvarium. The micro FE models did not indicate any anisotropy attributable to the pores observable under µCT. Published by Elsevier Ltd.

Functional Imaging of Human Vestibular Cortex Activity Elicited by Skull Tap and Auditory Tone Burst

NASA Technical Reports Server (NTRS)

Noohi, F.; Kinnaird, C.; Wood, S.; Bloomberg, J.; Mulavara, A.; Seidler, R.

2016-01-01

The current study characterizes brain activation in response to two modes of vestibular stimulation: skull tap and auditory tone burst. The auditory tone burst has been used in previous studies to elicit either the vestibulo-spinal reflex (saccular-mediated colic Vestibular Evoked Myogenic Potentials (cVEMP)), or the ocular muscle response (utricle-mediated ocular VEMP (oVEMP)). Some researchers have reported that air-conducted skull tap elicits both saccular and utricle-mediated VEMPs, while being faster and less irritating for the subjects. However, it is not clear whether the skull tap and auditory tone burst elicit the same pattern of cortical activity. Both forms of stimulation target the otolith response, which provides a measurement of vestibular function independent from semicircular canals. This is of high importance for studying otolith-specific deficits, including gait and balance problems that astronauts experience upon returning to earth. Previous imaging studies have documented activity in the anterior and posterior insula, superior temporal gyrus, inferior parietal lobule, inferior frontal gyrus, and the anterior cingulate cortex in response to different modes of vestibular stimulation. Here we hypothesized that skull taps elicit similar patterns of cortical activity as the auditory tone bursts, and previous vestibular imaging studies. Subjects wore bilateral MR compatible skull tappers and headphones inside the 3T GE scanner, while lying in the supine position, with eyes closed. Subjects received both forms of the stimulation in a counterbalanced fashion. Pneumatically powered skull tappers were placed bilaterally on the cheekbones. The vibration of the cheekbone was transmitted to the vestibular system, resulting in the vestibular cortical response. Auditory tone bursts were also delivered for comparison. To validate our stimulation method, we measured the ocular VEMP outside of the scanner. This measurement showed that both skull tap and auditory tone burst elicited vestibular evoked myogenic potentials, indicated by eye muscle responses. We further assessed subjects' postural control and its correlation with vestibular cortical activity. Our results provide the first evidence of using skull taps to elicit vestibular activity inside the MRI scanner. By conducting conjunction analyses we showed that skull taps elicit the same activation pattern as auditory tone bursts (superior temporal gyrus), and both modes of stimulation activate previously identified vestibular cortical regions. Additionally, we found that skull taps elicit more robust vestibular activity compared to auditory tone bursts, with less reported aversive effects. This further supports that the skull tap could replace auditory tone burst stimulation in clinical interventions and basic science research. Moreover, we observed that greater vestibular activation is associated with better balance control. We showed that not only the quality of balance (indicated by the amount of body sway) but also the ability to maintain balance for a longer time (indicated by the balance time) was associated with individuals' vestibular cortical excitability. Our findings support an association between vestibular cortical activity and individual differences in balance. In sum, we found that the skull tap stimulation results in activation of canonical vestibular cortex, suggesting an equally valid, but more tolerable stimulation method compared to auditory tone bursts. This is of high importance in longitudinal vestibular assessments, in which minimizing aversive effects may contribute to higher protocol adherence.

A case of loss of consciousness with contralateral acute subdural haematoma during awake craniotomy

PubMed Central

Kamata, Kotoe; Maruyama, Takashi; Nitta, Masayuki; Ozaki, Makoto; Muragaki, Yoshihiro; Okada, Yoshikazu

2014-01-01

We are reporting the case of a 56-year-old woman who developed loss of consciousness during awake craniotomy. A thin subdural haematoma in the contralateral side of the craniotomy was identified with intraoperative magnetic resonance imaging and subsequently removed. Our case indicates that contralateral acute subdural haematoma could be a cause of deterioration of the conscious level during awake craniotomy. PMID:25301378

Epidemiology of Moderate-to-Severe Penetrating Versus Closed Traumatic Brain Injury in the Iraq and Afghanistan Wars

DTIC Science & Technology

2012-01-01

Craniotomy 1.21 incision and drainage of cranial sinus 1.23 reopening of craniotomy site 1.24 other craniotomy 1.31 incision of cerebral meninges 1.39 other...Any intervention 401 (51.8) 102 (21.2) 503 (40.1) G0.0001 ICP monitoring 249 (32.2) 77 (16.0) 326 (26.0) G0.0001 Craniotomy 167 (21.6) 30 (6.2) 197

Awake craniotomy: improving the patient's experience.

PubMed

Potters, Jan-Willem; Klimek, Markus

2015-10-01

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients. Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms. Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.

Trans-falcine and contralateral sub-frontal electrode placement in pediatric epilepsy surgery: technical note.

PubMed

Pindrik, Jonathan; Hoang, Nguyen; Tubbs, R Shane; Rocque, Brandon J; Rozzelle, Curtis J

2017-08-01

Phase II monitoring with intracranial electroencephalography (ICEEG) occasionally requires bilateral placement of subdural (SD) strips, grids, and/or depth electrodes. While phase I monitoring often demonstrates a preponderance of unilateral findings, individual studies (video EEG, single photon emission computed tomography [SPECT], and positron emission tomography [PET]) can suggest or fail to exclude a contralateral epileptogenic onset zone. This study describes previously unreported techniques of trans-falcine and sub-frontal insertion of contralateral SD grids and depth electrodes for phase II monitoring in pediatric epilepsy surgery patients when concern about bilateral abnormalities has been elicited during phase I monitoring. Pediatric patients with medically refractory epilepsy undergoing stage I surgery for phase II monitoring involving sub-frontal and/or trans-falcine insertion of SD grids and/or depth electrodes at the senior author's institution were retrospectively reviewed. Intra-operative technical details of sub-frontal and trans-falcine approaches were studied, while intra-operative complications or events were noted. Operative techniques included gentle subfrontal retraction and elevation of the olfactory tracts (while preserving the relationship between the olfactory bulb and cribriform plate) to insert SD grids across the midline for coverage of the contralateral orbito-frontal regions. Trans-falcine approaches involved accessing the inter-hemispheric space, bipolar cauterization of the anterior falx cerebri below the superior sagittal sinus, and sharp dissection using a blunt elevator and small blade scalpel. The falcine window allowed contralateral SD strip, grid, and depth electrodes to be inserted for coverage of the contralateral frontal regions. The study cohort included seven patients undergoing sub-frontal and/or trans-falcine insertion of contralateral SD strip, grid, and/or depth electrodes from February 2012 through June 2015. Five patients (71%) experienced no intra-operative events related to contralateral ICEEG electrode insertion. Intra-operative events of frontal territory venous engorgement (1/7, 14%) due to sacrifice of anterior bridging veins draining into the SSS and avulsion of a contralateral bridging vein (1/7, 14%), probably due to prior anterior corpus callosotomy, each occurred in one patient. There were no intra-operative or peri-operative complications in any of the patients studied. Two patients required additional surgery for supplemental SD strip and/or depth electrodes via burr hole craniectomy to enhance phase II monitoring. All patients proceeded to stage II surgery for resection of ipsilateral epileptogenic onset zones without adverse events. Trans-falcine and sub-frontal insertion of contralateral SD strip, grid, and depth electrodes are previously unreported techniques for achieving bilateral frontal coverage in phase II monitoring in pediatric epilepsy surgery. This technique obviates the need for contralateral craniotomy and parenchymal exposure with limited, remediable risks. Larger case series using the method described herein are now necessary.

Cosmetic and functional reconstruction achieved using a split myofascial bone flap for pterional craniotomy. Technical note.

PubMed

Matsumoto, K; Akagi, K; Abekura, M; Ohkawa, M; Tasaki, O; Tomishima, T

2001-04-01

Cosmetic deformities that appear following pterional craniotomy are usually caused by temporal muscle atrophy, injury to the frontotemporal branch of the facial nerve, or bone pits in the craniotomy line. To resolve these problems during pterional craniotomy, an alternative method was developed in which a split myofascial bone flap and a free bone flap are used. The authors have used this method in the treatment of 40 patients over the last 3 years. Excellent cosmetic and functional results have been obtained. This method can provide wide exposure similar to that achieved using Yaşargil's interfascial pterional craniotomy, without limiting the operative field with a bulky temporal muscle flap.

Mapping connectivity damage in the case of Phineas Gage.

PubMed

Van Horn, John Darrell; Irimia, Andrei; Torgerson, Carinna M; Chambers, Micah C; Kikinis, Ron; Toga, Arthur W

2012-01-01

White matter (WM) mapping of the human brain using neuroimaging techniques has gained considerable interest in the neuroscience community. Using diffusion weighted (DWI) and magnetic resonance imaging (MRI), WM fiber pathways between brain regions may be systematically assessed to make inferences concerning their role in normal brain function, influence on behavior, as well as concerning the consequences of network-level brain damage. In this paper, we investigate the detailed connectomics in a noted example of severe traumatic brain injury (TBI) which has proved important to and controversial in the history of neuroscience. We model the WM damage in the notable case of Phineas P. Gage, in whom a "tamping iron" was accidentally shot through his skull and brain, resulting in profound behavioral changes. The specific effects of this injury on Mr. Gage's WM connectivity have not previously been considered in detail. Using computed tomography (CT) image data of the Gage skull in conjunction with modern anatomical MRI and diffusion imaging data obtained in contemporary right handed male subjects (aged 25-36), we computationally simulate the passage of the iron through the skull on the basis of reported and observed skull fiducial landmarks and assess the extent of cortical gray matter (GM) and WM damage. Specifically, we find that while considerable damage was, indeed, localized to the left frontal cortex, the impact on measures of network connectedness between directly affected and other brain areas was profound, widespread, and a probable contributor to both the reported acute as well as long-term behavioral changes. Yet, while significantly affecting several likely network hubs, damage to Mr. Gage's WM network may not have been more severe than expected from that of a similarly sized "average" brain lesion. These results provide new insight into the remarkable brain injury experienced by this noteworthy patient.

Prognostic Factors in Glioblastoma: Is There a Role for Epilepsy?

PubMed Central

DOBRAN, Mauro; NASI, Davide; CHIRIATTI, Stefano; GLADI, Maurizio; di SOMMA, Lucia; IACOANGELI, Maurizio; SCERRATI, Massimo

2018-01-01

The prognostic relevance of epilepsy at glioblastoma (GBMs) onset is still under debate. In this study, we analyzed the value of epilepsy and other prognostic factors on GBMs survival. We retrospectively analyzed the clinical, radiological, surgical and histological data in 139 GBMs. Seizures were the presenting symptoms in 50 patients out of 139 (35.9%). 123 patients (88%) were treated with craniotomy and tumor resection while 16 (12%) with biopsy. The median overall survival was 9.9 months from surgery. At univariable Cox regression, the factors that significantly improved survival were age less than 65 years (P = 0.0015), focal without impairment of consciousness seizures at presentation (P = 0.043), complete surgical resection (P < 0.001), pre-operative Karnofsky performance status (KPS) > 70 (P = 0.015), frontal location (P < 0.001), radiotherapy (XRT) plus concomitant and adjuvant TMZ (P < 0.001). A multivariable Cox regression showed that the complete surgical resection (P < 0.0001), age less than 65 years (P = 0.008), frontal location (P = 0.0001) and XRT adjuvant temozolomide (TMZ) (P < 0.0001) were independent factors on longer survival. In our series epilepsy at presentation is not an independent prognostic factor for longer survival in GBM patients. Only in the subgroup of patients with focal seizures without impairment of consciousness, epilepsy was associated with an increased significant overall survival at univariate analysis (P = 0.043). Main independent factors for relatively favorable GBMs outcome are complete tumor resection plus combined XRT-TMZ, frontal location and patient age below 65 years old. PMID:29343677

Anaesthesia for awake craniotomy is safe and well-tolerated.

PubMed

Andersen, Jakob Hessel; Olsen, Karsten Skovgaard

2010-10-01

Awake craniotomy for tumour resection has been performed at Glostrup Hospital since 2004. We describe and discuss the various anaesthetic approaches for such surgery and retrospectively analyse the 44 planned awake craniotomies performed at Glostrup Hospital. The surgery falls into four phases: craniotomy, mapping, tumour resection and closing. Three methods are being used: monitored anaesthetic care, asleep-awake-asleep and asleep-awake (AA). Anaesthesia is induced and maintained with propofol and remifentanil. A laryngeal mask (LM) is used as an airway during the craniotomy phase. In the AA method, patients are mapped and the tumour is resected while the patient is awake. A total of 41 of 44 planned AA craniotomies were performed. Three had to be converted into general anaesthesia (GA) due to tight brain, leaking LM and tumour haemorrhage, respectively. The following complications were observed: bradycardia 10%, leaking LM 5%, nausea 10%, vomiting 5%, focal seizures 28%, generalized seizures 10%, hypoxia 2%, hypotension 5% and hypertension 2%. Our results comply well with the international literature in terms of complications related to haemodynamics, respiration, seizures, vomiting and nausea and in terms of patient satisfaction. Awake craniotomy is a well-tolerated procedure with potential benefits. More prospective randomized studies are required.

Nonopioid anesthesia for awake craniotomy: a case report.

PubMed

Wolff, Diane L; Naruse, Robert; Gold, Michele

2010-02-01

Awake craniotomy is becoming more popular as a neurosurgical technique that allows for increased tumor resection and decreased postoperative neurologic morbidity. This technique, however, presents many challenges to both the neurosurgeon and anesthetist. An ASA class II, 37-year-old man with recurrent oligodendroglioma presented for repeated craniotomy. Prior craniotomy under general anesthesia resulted in residual neurologic deficits. An awake craniotomy was planned to allow for intraoperative testing for maximum tumor resection and avoidance of neurologic morbidity. The patient was sedated with propofol, and bupivacaine was infiltrated for placement of Mayfield tongs and skin incision. Following exposure of brain tissue, propofol infusion was discontinued to allow for patient cooperation during the procedure. Speech, motor, and sensory testing occurred during tumor resection until resection stopped after onset of weakness in the right arm. The propofol infusion was resumed while the cranium was closed and Mayfield tongs removed. The patient was awake, alert, oriented, and able to move all extremities but had residual weakness in the right forearm. Awake craniotomy requires appropriate patient selection, knowledge of the surgeon's skill, and a thorough anesthesia plan. This case report discusses the clinical and anesthetic management for awake craniotomy and reviews the literature.

Awake Craniotomy: First-Year Experiences and Patient Perception.

PubMed

Joswig, Holger; Bratelj, Denis; Brunner, Thomas; Jacomet, Alfred; Hildebrandt, Gerhard; Surbeck, Werner

2016-06-01

Awake craniotomy for brain lesions in or near eloquent brain regions enables neurosurgeons to assess neurologic functions of patients intraoperatively, reducing the risk of permanent neurologic deficits and increasing the extent of resection. A retrospective review was performed of a consecutive series of patients with awake craniotomies in the first year of their introduction to our tertiary non-university-affiliated neurosurgery department. Operation time, complications, and neurologic outcome were assessed, and patient perception of awake craniotomy was surveyed using a mailed questionnaire. There were 24 awake craniotomies performed in 22 patients for low-grade/high-grade gliomas, cavernomas, and metastases (average 2 cases per month). Mean operation time was 205 minutes. Failure of awake craniotomy because of intraoperative seizures with subsequent postictal impaired testing or limited cooperation occurred in 2 patients. Transient neurologic deficits occurred in 29% of patients; 1 patient sustained a permanent neurologic deficit. Of the 18 patients (82%) who returned the questionnaire, only 2 patients recalled significant fear during surgery. Introducing awake craniotomy to a tertiary non-university-affiliated neurosurgery department is feasible and resulted in reasonable operation times and complication rates and high patient satisfaction. Copyright © 2016 Elsevier Inc. All rights reserved.

Workload Trend Analysis for the Military Graduate Medical Education Program in San Antonio

DTIC Science & Technology

2005-05-25

Procedures 57 Introduction and Methodology 57 Results and Discussion 58 Craniotomy 61 Introduction and Methodology 61 Results and Discussion 62...distribution of major vascular procedures by age group for FY 00-04 36. WHMC and BAMC craniotomies for FY 00-04 by age group 37. WHMC and BAMC FY 00-04...average craniotomies by age group compared to required average based on RRC requirement 38. WHMC and BAMC distribution of craniotomies by age group for

The history of craniotomy for headache treatment.

PubMed

Assina, Rachid; Sarris, Christina E; Mammis, Antonios

2014-04-01

Both the history of headache and the practice of craniotomy can be traced to antiquity. From ancient times through the present day, numerous civilizations and scholars have performed craniotomy in attempts to treat headache. Today, surgical intervention for headache management is becoming increasingly more common due to improved technology and greater understanding of headache. By tracing the evolution of the understanding of headache alongside the practice of craniotomy, investigators can better evaluate the mechanisms of headache and the therapeutic treatments used today.

Teaching and sustainably implementing awake craniotomy in resource-poor settings.

PubMed

Howe, Kathryn L; Zhou, Guosheng; July, Julius; Totimeh, Teddy; Dakurah, Thomas; Malomo, Adefolarin O; Mahmud, Muhammad R; Ismail, Nasiru J; Bernstein, Mark A

2013-12-01

Awake craniotomy for brain tumor resection has the benefit of avoiding a general anesthetic and decreasing associated costs (e.g., intensive care unit beds and intravenous line insertion). In low- and middle-income countries, significant resource limitations for the system and individual make awake craniotomy an ideal tool, yet it is infrequently used. We sought to determine if awake craniotomy could be effectively taught and implemented safely and sustainably in low- and middle-income countries. A neurosurgeon experienced in the procedure taught awake craniotomy to colleagues in China, Indonesia, Ghana, and Nigeria during the period 2007-2012. Patients were selected on the basis of suspected intraaxial tumor, absence of major dysphasia or confusion, and ability to tolerate the positioning. Data were recorded by the local surgeons and included preoperative imaging, length of hospital admission, final pathology, postoperative morbidity, and mortality. Awake craniotomy was performed for 38 cases of suspected brain tumor; most procedures were completed independently. All patients underwent preoperative computed tomography or magnetic resonance imaging. In 64% of cases, patients remained in the hospital <10 days. The most common pathology was high-grade glioma, followed by meningioma, low-grade glioma, and metastasis. No deaths occurred, and no case required urgent intubation. The most common perioperative and postoperative issue was seizure, with 1 case of permanent postoperative deficit. Awake craniotomy was successfully taught and implemented in 6 neurosurgical centers in China, Indonesia, Ghana, and Nigeria. Awake craniotomy is safe, resource-sparing, and sustainable. The data suggest awake craniotomy has the potential to significantly improve access to neurosurgical care in resource-challenged settings. Copyright © 2013 Elsevier Inc. All rights reserved.

Curvularia brain abscess.

PubMed

Gadgil, Nisha; Kupferman, Michael; Smitherman, Sheila; Fuller, Gregory N; Rao, Ganesh

2013-01-01

Curvularia is a ubiquitous dematiaceous fungus that is a very rare but often fatal cause of infection in the central nervous system (CNS). In this report, we describe a patient with chronic sinusitis who presented with a Curvularia abscess of the skull base extending into the left frontal lobe. She was successfully treated with aggressive surgical resection and antibiotic therapy. In the published literature, this patient to our knowledge represents the longest period of disease-free follow-up in those afflicted with CNS Curvularia infection, indicating the importance of proper diagnosis and aggressive surgical debridement for a successful outcome. Copyright © 2012 Elsevier Ltd. All rights reserved.

Cranial injury caused by penetrating non-missile foreign body: an autopsy case.

PubMed

Eren, B; Türkmen, N; Toprak Ergönen, A; Gündogmus, U N

2012-10-01

Presented case was 32-year-old male marble worker, who underwent industrial accident at workplace. On gross physical examination; on forehead region round skin wound in 0.9 cm diameter was detected, radiological examination showed the image of metallic object. in the skull cavity. Brain dissection showed obvious brain injury, haemorrahge explaining the pattern of injury caused by the metallic bodys path, from left frontal lobe to the left cerebellar hemisphere was identified. We presented rare case of penetrating injury of the cranial region caused by non-missile foreign body. cranial injury - non-missile foreign body - autopsy.

The Royal Book by Haly Abbas from the 10th century: one of the earliest illustrations of the surgical approach to skull fractures.

PubMed

Aciduman, Ahmet; Arda, Berna; Kahya, Esin; Belen, Deniz

2010-12-01

Haly Abbas was one of the pioneering physicians and surgeons of the Eastern world in the 10th century who influenced the Western world by his monumental work, The Royal Book. The book was first partly translated into Latin by Constantinus Africanus in the 11th century without citing the author's name. Haly Abbas was recognized in Europe after full translation of The Royal Book by Stephen of Antioch in 1127. The Royal Book has been accepted as an early source of jerrah-names (surgical books) in the Eastern world. The chapters regarding cranial fractures in Haly Abbas' work include unique management strategies for his period with essential quotations from Paul of Aegina's work Epitome. Both authors preferred free bone flap craniotomy in cranial fractures. Although Paul of Aegina, a Byzantine physician and surgeon, was a connection between ancient traditions and Islamic interpretation, Haly Abbas seemed to play a bridging role between the Roman-Byzantine and the School of Salerno in Europe.

Carotid-Falciform Optic Neuropathy: Microsurgical Treatment.

PubMed

Woodall, M Neil; Alleyne, Cargill H

2017-08-01

Several recent reports have implicated vascular ectasia and vessel contact in dysfunction of the visual apparatus. A subset of patients with prechiasmatic visual deterioration have an ectatic internal carotid artery (ICA) that displaces and flattens the optic nerve (ON) rostrally as the ON exits the skull base. We describe a proposed pathophysiologic mechanism and a straightforward surgical technique for dealing with this problem. Via an ipsilateral pterional craniotomy, the bony roof of the optic canal is removed. The falciform ligament is opened in parallel to the ON. Adhesions between the ICA and ON are then dissected, and a Teflon pledget is placed between the ICA and ON to complete the decompression. Patients both in the literature and in this series experienced an improvement in their vision postoperatively. We propose that 3 mechanisms contribute to this caroticofalciform optic neuropathy: 1) mass effect from ICA ectasia, 2) ON irritation from vessel pulsatility, and 3) indirect compression by the falciform ligament from above. This disease process can be treated safely using standard microsurgical techniques with excellent outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury.

PubMed

Burns, Emma C M; Grool, Anne M; Klassen, Terry P; Correll, Rhonda; Jarvis, Anna; Joubert, Gary; Bailey, Benoit; Chauvin-Kimoff, Laurel; Pusic, Martin; McConnell, Don; Nijssen-Jordan, Cheri; Silver, Norm; Taylor, Brett; Osmond, Martin H

2016-05-01

Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship. This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture. ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1). Large and boggy and nonfrontal scalp hematomas had the strongest association with the presence of ICI in this large pediatric cohort. Although children 0 to 6 months of age were at highest odds, the presence of a scalp hematoma also independently increased the odds of ICI in older children and adolescents. The presence of a linear skull fracture only partially explained this relation, indicating that ruling out a skull fracture beneath a hematoma does not obviate the risk of intracranial pathology. © 2016 by the Society for Academic Emergency Medicine.

Pediatric Awake Craniotomy for Brain Lesions.

PubMed

Akay, Ali; Rükşen, Mete; Çetin, H Yurday; Seval, H Özer; İşlekel, Sertaç

2016-01-01

Awake craniotomy is a special method to prevent motor deficits during the resection of lesions that are located in, or close to, functional areas. Although it is more commonly performed in adult patients, reports of pediatric cases undergoing awake craniotomy are limited in the literature. In our clinic, where we frequently use awake craniotomy in adult patients, we performed this method in 2 selected pediatric cases for lesion surgery. At an early age, these 2 cases diagnosed with epilepsy presented cerebral lesions, but since the lesions enclosed functional areas, surgical resection was not regarded as a treatment option at this time. In these 2 pediatric cases, we successfully completed lesion surgery with awake craniotomy. The method and the techniques employed during surgery are presented concomitant with other reports in the literature. © 2016 S. Karger AG, Basel.

Management of supratentorial cavernous malformations: craniotomy versus gammaknife radiosurgery.

PubMed

Shih, Yang-Hsin; Pan, David Hung-Chi

2005-02-01

Although craniotomy is the preferred treatment for symptomatic solitary supratentorial cavernous malformation (CM), radiosurgery is also an option. Our aim was to see which of these strategies was the most effective and under what circumstances. Of the 46 patients with solitary supratentorial CM that we retrospectively studied, 24 presented with seizures, 16 with focal neurological deficits due to intracerebral hemorrhage, and 6 with both seizures and bleeding. Sixteen were treated with craniotomy and 30 with gammaknife radiosurgery (GKRS). The main outcome measures for comparing craniotomy with GKRS were the proportion of postoperative seizure-free patients and the proportion of patients in whom no rebleeding occurred. Of patients presenting with seizures with/without bleeding, a significantly higher proportion of the craniotomy group than the GKRS group became and remained seizure-free (11/14 [79%] versus 4/16 [25%]; P < 0.002), and of those presenting with bleeding with/without seizures, a somewhat (though nonsignificantly) higher proportion did not rebleed (4/4 [100%] versus 12/18 [67%]) after surgery. The remaining 2 of the 16 craniotomy patients did not rebleed and had no residual tumor at follow up. Twelve of the 30 GKRS patients had evidence of tumor regression at follow up. In the clinical management of solitary supratentorial CM, craniotomy for lesionectomy resulted in better seizure control and rebleeding avoidance than GKRS.

Evolution of Minimally Invasive Approaches to the Sella and Parasellar Region

PubMed Central

Louis, Robert G.; Eisenberg, Amy; Barkhoudarian, Garni; Griffiths, Chester; Kelly, Daniel F.

2014-01-01

Introduction Given advancements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, and anatomical understanding, the endonasal endoscopic approach has rapidly evolved into a widely utilized technique for removal of sellar and parasellar tumors. Although pituitary adenomas and Rathke cleft cysts constitute the majority of lesions removed via this route, craniopharyngiomas, clival chordomas, parasellar meningiomas, and other lesions are increasingly removed using this approach. Paralleling the evolution of the endonasal route to the parasellar region, the supraorbital eyebrow craniotomy has also been increasingly used as an alternative minimally invasive approach to reach this skull base region. Similar to the endonasal route, the supraorbital route has been greatly facilitated by advances in endoscopy, along with development of more refined, low-profile instrumentation and surgical navigation technology. Objectives This review, encompassing both transcranial and transsphenoidal routes, will recount the high points and advances that have made minimally invasive approaches to the sellar region possible, the evolution of these approaches, and their relative indications and technical nuances. Data Synthesis The literature is reviewed regarding the evolution of surgical approaches to the sellar region beginning with the earliest attempts and emphasizing technological advances, which have allowed the evolution of the modern technique. The surgical techniques for both endoscopic transsphenoidal and supraorbital approaches are described in detail. The relative indications for each approach are highlighted using case illustrations. Conclusions Although tremendous advances have been made in transitioning toward minimally invasive transcranial and transsphenoidal approaches to the sella, further work remains to be done. Together, the endonasal endoscopic and the supraorbital endoscope-assisted approaches are complementary minimally invasive routes to the parasellar region. PMID:25992138

Prospective transfrontal sheep model of skull-base reconstruction using vascularized mucosa.

PubMed

Mueller, Sarina K; Scangas, George; Amiji, Mansor M; Bleier, Benjamin S

2018-05-01

No high-fidelity animal model exists to examine prospective wound healing following vascularized reconstruction of the skull base. Such a model would require the ability to study the prospective behavior of vascularized mucosal repairs of large dural and arachnoid defects within the intranasal environment. The objective of this study was to therefore develop and validate a novel, in vivo, transfrontal sheep model of cranial base repair using vascularized sinonasal mucosa. Twelve transfrontal craniotomy and 1.5-cm durotomy reconstructions were performed in 60-kg to 70-kg Dorset/Ovis Aries sheep using vascularized mucosa with or without an adjunctive Biodesign™ underlay graft (n = 6 per group). Histologic outcomes were graded (scale, 0 to 4) by a blinded veterinary histopathologist after 7, 14, and 28 days for a range of wound healing parameters. All sheep tolerated the surgery, which required 148 ± 33 minutes. By day 7, the mucosa was fully adherent with complete partitioning of the sinus and intracranial compartments. Fibroblast infiltration and flap neovascularization scores significantly increased between day 7 (0.3 ± 0.5 and 0.0 ± 0.0) and day 28 (4.0 ± 0.0, p = 0.01 and 2.0 ± 0.8, p = 0.01; respectively), while hemorrhage scores significantly decreased from 2.5 ± 0.6 to 0.0 ± 0.0 (p = 0.01). The inflammatory scores were not significantly different between the heterologous graft and control sides. The described sheep model accurately reflects prospective intranasal wound healing following vascularized mucosal reconstruction of dural defects. This model can be used in future studies to examine novel reconstructive materials, tissue glues, and transmucosal drug delivery to the central nervous system. © 2017 ARS-AAOA, LLC.

Nocardia farcinica brain abscess: epidemiology, pathophysiology, and literature review.

PubMed

Kumar, V Anil; Augustine, Deepthi; Panikar, Dilip; Nandakumar, Aswathy; Dinesh, Kavitha R; Karim, Shamsul; Philip, Rosamma

2014-10-01

Infections caused by Nocardia farcinica are potentially lethal because of the organism's tendency to disseminate and resist antibiotics. Central nervous system involvement has been documented in 30% of infections caused N. farcinica. Case report and review of the literature. A case of primary brain abscess caused by N. farcinica, identified by 16SrRNA sequencing, is presented, and 39 cases reported previously in the literature are reviewed. Our patient underwent a neuronavigation-guided right frontal craniotomy and was treated with trimethoprim/sulfamethoxazole and amoxicillin-clavulanic acid for 12 mo. He showed marginal improvement in his prior left hemiparesis at the last review 14 months later. Cases of N. farcinica infections are being reported increasingly because of recent changes in taxonomy and diagnostic methodology. This change in epidemiology has implications for therapy because of the organism's pathogenicity and natural resistance to multiple antimicrobial agents, including third-generation cephalosporins. Any delay in starting appropriate antibiotic therapy can have adverse consequences.

Actinomyces meyeri brain abscess following dental extraction

PubMed Central

Clancy, U; Ronayne, A; Prentice, M B; Jackson, A

2015-01-01

We describe the rare occurrence of an Actinomyces meyeri cerebral abscess in a 55-year-old woman following a dental extraction. This patient presented with a 2-day history of hemisensory loss, hyper-reflexia and retro-orbital headache, 7 days following a dental extraction for apical peridonitis. Neuroimaging showed a large left parietal abscess with surrounding empyema. The patient underwent craniotomy and drainage of the abscess. A. meyeri was cultured. Actinomycosis is a rare cause of cerebral abscess. The A. meyeri subtype is particularly rare, accounting for less than 1% of specimens. This case describes an unusually brief course of the disease, which is usually insidious. Parietal lobe involvement is unusual as cerebral abscesses usually have a predilection for the frontal and temporal regions of the brain. Although there are no randomised trials to guide therapy, current consensus is to use a prolonged course of intravenous antibiotics, followed by 6–12 months of oral therapy. PMID:25870213

Mucoepidermoid Carcinoma in the Skull of an Orange-winged Amazon Parrot (Amazona amazonica).

PubMed

Nau, Melissa R; Carpenter, James W; Lin, Denise; Narayanan, Sanjeev; Hallman, Mackenzie

2017-09-01

A 33-year-old female intact orange-winged Amazon parrot (Amazona amazonica) presented for a slowly growing mass over the right eye. A computed tomography scan performed with and without intravenous contrast revealed a heterogeneous mixed soft tissue and mineral-dense mass with a small area of non-contrast-enhancing fluid density located between the orbits at the caudal aspect of the nasal passages, with associated lysis of the right caudal nasal passage and the right frontal bone. Following euthanasia, the mass was found to consist of soft tissue between the right eye and nostril over the right frontal bone. Lysis of the underlying bone resulted in a bony defect leading into the infraorbital sinus along the dorsorostral aspect of the right eye. Histopathology revealed an unencapsulated, poorly demarcated, highly cellular neoplasm composed of islands and trabeculae of neoplastic cells embedded in abundant loose fibrovascular stroma which completely obliterated the cortical bone and sinuses of the rostral skull and infiltrated the surrounding muscle and soft tissue. Histologically, the tumor was consistent with a high-grade mucoepidermoid carcinoma, characterized by the presence of epidermoid, intermediate, and mucous-producing cell types. No evidence of metastasis was identified. The tissue of origin was suspected to be salivary or nasal mucous glands, but was difficult to confirm due to distortion of normal tissue architecture as a result of the tumor. Although mucoepidermoid carcinomas are a common salivary gland tumor in human medicine, they are not well recognized in avian species, and no specific case reports exist describing this pathology in an Amazon parrot. Despite the lack of distinct salivary glands in most avian species, mucoepidermoid carcinomas can occur, can cause significant clinical disease, and should be included as a differential diagnosis for avian patients presenting with similar lesions.

Macroscopic Innervation of the Dura Mater Covering the Middle Cranial Fossa in Humans Correlated to Neurovascular Headache

PubMed Central

Lee, Shin-Hyo; Hwang, Seung-Jun; Koh, Ki-Seok; Song, Wu-Chul; Han, Sang-Don

2017-01-01

The trigeminovascular system within the cranial dura mater is a possible cause of headaches. The aim of this study is to investigate macroscopically dural innervation around the middle meningeal artery (MMA) in the middle cranial fossa. Forty-four sides of the cranial dura overlying the skull base obtained from 24 human cadavers were stained using Sihler’s method. Overall, the nervus spinosus (NS) from either the maxillary or mandibular trigeminal divisions ran along the lateral wall of the middle meningeal vein rather than that of the MMA. Distinct bundles of the NS running along the course of the frontal branches of the MMA were present in 81.8% of cases (N = 36). Others did not form dominant nerve bundles, instead giving off free nerve endings along the course of the MMA or dural connective tissue. The distribution of these nerve endings was similar to that of the course of the frontal, parietal and petrosal branches of the MMA (11.4%). The others were not restricted to a perivascular plexus, crossing the dural connective tissues far from the MMA (6.8%). These findings indicate that the NS generally travels alongside the course of the frontal branches of the MMA and terminates in the vicinity of the pterion. PMID:29311855

Macroscopic Innervation of the Dura Mater Covering the Middle Cranial Fossa in Humans Correlated to Neurovascular Headache.

PubMed

Lee, Shin-Hyo; Hwang, Seung-Jun; Koh, Ki-Seok; Song, Wu-Chul; Han, Sang-Don

2017-01-01

The trigeminovascular system within the cranial dura mater is a possible cause of headaches. The aim of this study is to investigate macroscopically dural innervation around the middle meningeal artery (MMA) in the middle cranial fossa. Forty-four sides of the cranial dura overlying the skull base obtained from 24 human cadavers were stained using Sihler's method. Overall, the nervus spinosus (NS) from either the maxillary or mandibular trigeminal divisions ran along the lateral wall of the middle meningeal vein rather than that of the MMA. Distinct bundles of the NS running along the course of the frontal branches of the MMA were present in 81.8% of cases ( N = 36). Others did not form dominant nerve bundles, instead giving off free nerve endings along the course of the MMA or dural connective tissue. The distribution of these nerve endings was similar to that of the course of the frontal, parietal and petrosal branches of the MMA (11.4%). The others were not restricted to a perivascular plexus, crossing the dural connective tissues far from the MMA (6.8%). These findings indicate that the NS generally travels alongside the course of the frontal branches of the MMA and terminates in the vicinity of the pterion.

Endocranial shape asymmetries in Pan paniscus, Pan troglodytes and Gorilla gorilla assessed via skull based landmark analysis.

PubMed

Balzeau, Antoine; Gilissen, Emmanuel

2010-07-01

Brain shape asymmetries or petalias consist of the extension of one cerebral hemisphere beyond the other. A larger frontal or caudal projection is usually coupled with a larger lateral extent of the more projecting hemisphere relative to the other. The concurrence of these petalial components is characteristic of hominins. Studies aimed at quantifying petalial asymmetries in human and great ape endocasts rely on the definition of the midline of the endocranial surface. Studies of brain material show that, at least in humans, most of the medial surface of the left occipital lobe distorts along the midline and protrudes on to the right side, making it difficult for midline and corresponding left and right reference point identification. In order to accurately quantify and compare brain shape asymmetries in extant hominid species, we propose here a new protocol based on the objective definition of cranial landmarks. We describe and quantify for the first time in three dimensions the positions of frontal and occipital protrusions in large samples of Pan paniscus, Pan troglodytes and Gorilla gorilla. This study confirms the existence of frontal and occipital petalias in African apes. Moreover, the detailed analysis of the 3D structure of these petalias reveals shared features, as well as features that are unique to the different great ape species.

How I do it: Awake craniotomy.

PubMed

Hill, Ciaran Scott; Severgnini, Flavio; McKintosh, Edward

2017-01-01

Awake craniotomy allows continuous assessment of a patient's clinical and neurological status during open brain surgery. This facilitates early detection of interference with eloquent cortex, and hence can allow a surgeon to maximize resection margins without compromising neurological function. Awake craniotomy requires an effective scalp blockade, intraoperative assessment, and a carefully co-ordinated theatre team. A variety of clinical and electrophysiological techniques can be used to assess cortical function. Effective scalp blockade and awake craniotomy provides the opportunity to intraoperatively assess cortical function in the awake patient, thus providing an important neurosurgical option for lesions near eloquent cortex.

Quantifying bone thickness, light transmission, and contrast interrelationships in transcranial photoacoustic imaging

NASA Astrophysics Data System (ADS)

Lediju Bell, Muyinatu A.; Ostrowski, Anastasia K.; Li, Ke; Kaanzides, Peter; Boctor, Emad

2015-03-01

We previously introduced photoacoustic imaging to detect blood vessels surrounded by bone and thereby eliminate the deadly risk of carotid artery injury during endonasal, transsphenoidal surgeries. Light would be transmitted through an optical fiber attached to the surgical drill, while a transcranial probe placed on the temporal region of the skull receives photoacoustic signals. This work quantifies changes in photoacoustic image contrast as the sphenoid bone is drilled. Frontal bone from a human adult cadaver skull was cut into seven 3 cm x 3 cm chips and sanded to thicknesses ranging 1-4 mm. For 700-940 nm wavelengths, the average optical transmission through these specimens increased from 19% to 44% as bone thickness decreased, with measurements agreeing with Monte Carlo simulations within 5%. These skull specimens were individually placed in the optical pathway of a 3.5 mm diameter, cylindrical, vessel-mimicking photoacoustic target, as the laser wavelength was varied between 700-940 nm. The mean optical insertion loss and photoacoustic image contrast loss due to the bone specimens were 56-80% and 46-79%, respectively, with the majority of change observed when the bone was <=2 mm thick. The decrease in contrast is directly proportional to insertion loss over this thickness range by factors of 0.8-1.1 when multiple wavelengths are considered. Results suggest that this proportional relationship may be used to determine the amount of bone that remains to be drilled when the thickness is 2 mm or less.

[Pontomedullary lacerations and concomitant injuries: a review of possible underlying mechanisms].

PubMed

Živković, Vladimir; Nikolić, Slobodan

2013-01-01

Anatomically, brainstem is constituted of medulla oblongata, pons and mesencephalon. Traumatic lesions of brainstem most commonly occur on pontomedullary junction. There are several possible mechanisms of pontomedullary lacerations. The first mechanism includes impact to the chin, with or without a skull base fracture, and most often leads to this fatal injury, due to impact force transmission through the jawbone and temporomandibular joint. The second mechanism includes lateral and posterior head impacts with subsequent hinge fractures, where occurrence of pontomedullary lacerations in these cases may depend on the energy of impact, as well as on the exact position of the fracture line, but less so on the head's movement. The third mechanism includes frontoposterior hyperextension of the head, due to frontal impact, concomitant with fractures or dislocations of upper spine. In the fourth mechanism, there is an absence of direct impact to the head, due to the indirect force of action after feet or buttocks-first impact. Most of these cases are accompanied by ring fractures as well. In situations such as these, the impact force is transmitted up the spinal column and upper vertebrae, and telescopically intruded into the skull, causing brainstem laceration. The jawbone and other facial bones can act as shock absorbers, and their fracture could diminish the energy transfer towards the skull and protect the brain and brainstem from injury. In all the cases with pontomedullary laceration posterior neck dissection should be performed during the autopsy, since upper spine injuries are often associated with this type of injury.

A fire death with a rare finding: anthracosis or soot embolism?

PubMed

Rahimi, Razuin; Omar, Effat; Md Noor, Shahidan

2015-04-01

Charred human remains were found in the smoking ambers of a dying fire in an oil palm plantation in Selangor, Malaysia in the midnight of January 28, 2013. Investigations showed that palm fronds and rubber tires were used to light and sustain the blaze. At least four to five tires were estimated to be used based on the residual burnt metal wires at the site. The remains were brought to the Department of Forensic Medicine, Hospital Sungai Buloh, Selangor for post-mortem examination. Pre-autopsy imaging showed a fractured skull with presence of a bullet in the head. The body belonged to a male with unrecognizable facial features, pugilistic attitude, and reduced body size caused by fire damage with sparing of the posterior surface. A large fracture was present at the skull vault. An entry gunshot wound was observed on the left side of the body of mandible, which was associated with base of skull fracture. Heat-related fractures were also noted on the right side of the frontal bone. A projectile was retrieved from the right side of the occipital lobe. Further examination showed presence of soot and hyperaemic larynx, trachea, main bronchi, and oesophagus. Black spots measuring 1 to 2 mm were present on the surface and parenchyma of the heart, liver, pancreas and kidneys. Histopathology examination showed black particles within the vessels in the affected organs. We report this rare finding in a charred body and present a discussion based on published literature on this issue.

Patients' perspective on awake craniotomy for brain tumors-single center experience in Brazil.

PubMed

Leal, Rafael Teixeira Magalhaes; da Fonseca, Clovis Orlando; Landeiro, Jose Alberto

2017-04-01

Awake craniotomy with brain mapping is the gold standard for eloquent tissue localization. Patients' tolerability and satisfaction have been shown to be high; however, it is a matter of debate whether these findings could be generalized, since patients across the globe have their own cultural backgrounds and may perceive and accept this procedure differently. We conducted a prospective qualitative study about the perception and tolerability of awake craniotomy in a population of consecutive brain tumor patients in Brazil between January 2013 and April 2015. Seventeen patients were interviewed using a semi-structured model with open-ended questions. Patients' thoughts were grouped into five categories: (1) overall perception: no patient considered awake craniotomy a bad experience, and most understood the rationale behind it. They were positively surprised with the surgery; (2) memory: varied from nothing to the entire surgery; (3) negative sensations: in general, it was painless and comfortable. Remarks concerning discomfort on the operating table were made; (4) postoperative recovery: perception of the postoperative period was positive; (5) previous surgical experiences versus awake craniotomy: patients often preferred awake surgery over other surgery under general anesthesia, including craniotomies. Awake craniotomy for brain tumors was well tolerated and yielded high levels of satisfaction in a population of patients in Brazil. This technique should not be avoided under the pretext of compromising patients' well-being.

Patient response to awake craniotomy - a summary overview.

PubMed

Milian, Monika; Tatagiba, Marcos; Feigl, Guenther C

2014-06-01

Awake craniotomy is a valuable procedure since it allows brain mapping and live monitoring of eloquent brain functions. The advantage of minimizing resource utilization is also emphasized by some physicians in North America. Data on how well an awake craniotomy is tolerated by patients and how much stress it creates is available from different studies, but this topic has not consequently been summarized in a review of the available literature. Therefore, it is the purpose of this review to shed more light on the still controversially discussed aspect of an awake craniotomy. We reviewed the available English literature published until December 2013 searching for studies that investigated patients' responses to awake craniotomies. Twelve studies, published between 1998 and 2013, including 396 patients with awake surgery were identified. Eleven of these 12 studies set the focus on the perioperative time, one study focused on the later postoperative time. The vast majority of patients felt well prepared and overall satisfaction with the procedure was high. In the majority of studies up to 30 % of the patients recalled considerable pain and 10-14 % experienced strong anxiety during the procedure. The majority of patients reported that they would undergo an awake craniotomy again. A post traumatic stress disorder was present neither shortly nor years after surgery. However, a normal human response to such an exceptional situation can for instance be the delayed appearance of unintentional distressing recollections of the event despite the patients' satisfaction concerning the procedure. For selected patients, an awake craniotomy presents the best possible way to reduce the risk of surgery related neurological deficits. However, benefits and burdens of this type of procedure should be carefully considered when planning an awake craniotomy and the decision should serve the interests of the patient.

Integrative Review: Post-Craniotomy Pain in the Brain Tumor Patient

PubMed Central

Guilkey, Rebecca Elizabeth; Von Ah, Diane; Carpenter, Janet S.; Stone, Cynthia; Draucker, Claire B.

2015-01-01

Aim To conduct an integrative review to examine evidence of pain and associated symptoms in adult (≥ 21 years of age), post-craniotomy, brain tumor patients hospitalized on intensive care units. Background Healthcare providers believe craniotomies are less painful than other surgical procedures. Understanding how post-craniotomy pain unfolds over time will help inform patient care and aid in future research and policy development. Design Systematic literature search to identify relevant literature. Information abstracted using the Theory of Unpleasant Symptoms’ concepts of influencing factors, symptom clusters and patient performance. Inclusion criteria were indexed, peer-reviewed, full-length, English-language articles. Keywords were ‘traumatic brain injury,’ ‘pain, post-operative,’ ‘brain injuries,’ ‘postoperative pain,’ ‘craniotomy,’ ‘decompressive craniectomy,’ and ‘trephining.’ Data sources Medline, OVID, PubMed and CINAHL databases from 2000 – 2014. Review Method Cooper’s five-stage integrative review method was used to assess and synthesize literature. Results The search yielded 115 manuscripts, with 26 meeting inclusion criteria. Most studies were randomized, controlled trials conducted outside of the United States. All tested pharmacological pain interventions. Post-craniotomy brain tumor pain was well-documented and associated with nausea, vomiting and changes in blood pressure and impacted patient length of hospital stay, but there was no consensus for how best to treat such pain. Conclusion The Theory of Unpleasant Symptoms provided structure to the search. Post-craniotomy pain is experienced by patients, but associated symptoms and impact on patient performance remain poorly understood. Further research is needed to improve understanding and management of post-craniotomy pain in this population. PMID:26734710

Patient acceptance of awake craniotomy.

PubMed

Wrede, Karsten H; Stieglitz, Lennart H; Fiferna, Antje; Karst, Matthias; Gerganov, Venelin M; Samii, Madjid; von Gösseln, Hans-Henning; Lüdemann, Wolf O

2011-12-01

The aim of this study was to objectively assess the patients' acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas. Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data. The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p=0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales "postoperative pain" (p=0.02) and "physical disorders" (p=0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients' acceptance for AC. Previous studies have shown good patients' acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences. Copyright © 2011 Elsevier B.V. All rights reserved.

[Comparison of the intracranial pressure value in patients with hypertensive intracerebral hemorrhage treated with traditional craniotomy and puncture drainage].

PubMed

Song, Shao-jun; Fei, Zhou; Zhang, Xiang

2003-09-01

To compare the difference of intracranial pressure (ICP) in patients with hypertensive intracerebral hemorrhage (HICH) treated with two surgical procedures, traditional craniotomy and puncture drainage. One hundred and twelve cases with HICH were randomly divided into two groups. In one group, 60 patients were operated by traditional craniotomy and in another group, 52 cases by puncture drainage and urokinase treatment. In the meantime, ICP was monitored by placing catheter in lateral ventricle on the contralateral side of the hemorrhage. ICP values were recorded after operation at once, at 24 hours, 72 hours and 1 week. Although all the patients showed increased ICP, the increasing degree in patients treated with traditional craniotomy had lower ICP values (P<0.05 or P<0.01). Traditional craniotomy has advantages over puncture drainage for patients with HICH at least with respect to decreasing ICP.

[Awake craniotomy: analysis of complicated cases].

PubMed

Kulikov, A S; Kobyakov, G L; Gavrilov, A G; Lubnin, A Yu

2015-01-01

Awake craniotomy is recognized as method that can decrease the frequency of neurological complications after surgery for gliomas located near eloquent brain regions. Unfortunately good neurological outcome can't be ensured even by using of this technique. This paper discusses reasons and possible ways of prevention of such complications. 162 awake craniotomies were performed in our clinic. 152 of patients were discharged from the clinic with good outcome. In 10 (6%) cases sustained severe neurological deficit was noted. These complications were associated with anatomic or ischemic injury of subcortical pathways and internal capsule. Awake craniotomy is effective instrument of brain language mapping and prevention of neurological deterioration. Severe neurological complications of awake craniotomy are associated with underestimate neurosurgical risks, especially in terms of blood vessel injury and depth of resection. The main way of prevention of such complications is meticulous planning of operation and adequate using of mapping facilities.

Pediatric awake craniotomy for seizure focus resection with dexmedetomidine sedation-a case report.

PubMed

Sheshadri, Veena; Chandramouli, B A

2016-08-01

Resection of lesions near the eloquent cortex of brain necessitates awake craniotomy to reduce the risk of permanent neurologic deficits during surgery. There are limited reports of anesthetic management of awake craniotomy in pediatric patients. This report is on use of dexmedetomidine sedation for awake craniotomy in a 11-year-old child, without any airway adjuncts throughout the procedure. Dexmedetomidine infusion administered at a dosage of 0.2 to 0.7μg kg(-1) h(-1) provided adequate sedation for the entire procedure. There were no untoward incidents or any interference with electrocorticography, intraoperative stimulation, and functional mapping. Adequate preoperative visits and counseling of patient and parents regarding course and nature of events along with well-planned intraoperative management are of utmost importance in a pediatric age group for successful intraoperative awake craniotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

Combination of Continuous Dexmedetomidine Infusion with Titrated Ultra-Low-Dose Propofol-Fentanyl for an Awake Craniotomy

PubMed Central

Das, Samaresh; Al-Mashani, Ali; Suri, Neelam; Salhotra, Neeraj; Chatterjee, Nilay

2016-01-01

An awake craniotomy is a continuously evolving technique used for the resection of brain tumours from the eloquent cortex. We report a 29-year-old male patient who presented to the Khoula Hospital, Muscat, Oman, in 2016 with a two month history of headaches and convulsions due to a space-occupying brain lesion in close proximity with the left motor cortex. An awake craniotomy was conducted using a scalp block, continuous dexmedetomidine infusion and a titrated ultra-low-dose of propofolfentanyl. The patient remained comfortable throughout the procedure and the intraoperative neuropsychological tests, brain mapping and tumour resection were successful. This case report suggests that dexmedetomidine in combination with titrated ultra-low-dose propofolfentanyl are effective options during an awake craniotomy, ensuring optimum sedation, minimal disinhibition and a rapid recovery. To the best of the authors’ knowledge, this is the first awake craniotomy conducted successfully in Oman. PMID:27606116

Passive language mapping combining real-time oscillation analysis with cortico-cortical evoked potentials for awake craniotomy.

PubMed

Tamura, Yukie; Ogawa, Hiroshi; Kapeller, Christoph; Prueckl, Robert; Takeuchi, Fumiya; Anei, Ryogo; Ritaccio, Anthony; Guger, Christoph; Kamada, Kyousuke

2016-12-01

OBJECTIVE Electrocortical stimulation (ECS) is the gold standard for functional brain mapping; however, precise functional mapping is still difficult in patients with language deficits. High gamma activity (HGA) between 80 and 140 Hz on electrocorticography is assumed to reflect localized cortical processing, whereas the cortico-cortical evoked potential (CCEP) can reflect bidirectional responses evoked by monophasic pulse stimuli to the language cortices when there is no patient cooperation. The authors propose the use of "passive" mapping by combining HGA mapping and CCEP recording without active tasks during conscious resections of brain tumors. METHODS Five patients, each with an intraaxial tumor in their dominant hemisphere, underwent conscious resection of their lesion with passive mapping. The authors performed functional localization for the receptive language area, using real-time HGA mapping, by listening passively to linguistic sounds. Furthermore, single electrical pulses were delivered to the identified receptive temporal language area to detect CCEPs in the frontal lobe. All mapping results were validated by ECS, and the sensitivity and specificity were evaluated. RESULTS Linguistic HGA mapping quickly identified the language area in the temporal lobe. Electrical stimulation by linguistic HGA mapping to the identified temporal receptive language area evoked CCEPs on the frontal lobe. The combination of linguistic HGA and frontal CCEPs needed no patient cooperation or effort. In this small case series, the sensitivity and specificity were 93.8% and 89%, respectively. CONCLUSIONS The described technique allows for simple and quick functional brain mapping with higher sensitivity and specificity than ECS mapping. The authors believe that this could improve the reliability of functional brain mapping and facilitate rational and objective operations. Passive mapping also sheds light on the underlying physiological mechanisms of language in the human brain.

Dexmedetomidine in the Supratentorial Craniotomy

PubMed Central

Ilhan, Osman; Koruk, Senem; Serin, Gokcen; Erkutlu, Ibrahim; Oner, Unsal

2010-01-01

Objective: In this double-blind prospective clinical study, we investigated the effects of fentanyl and dexmedetomidine as adjuvant agents in supratentorial craniotomies on the following: hemodynamic changes during perioperative and recovery periods, brain edema perioperatively, recovery times and side effects, such as hypertension, shivering, nausea and vomiting. Materials and Methods: Thirty consenting ASA physical status I–II patients undergoing intracranial tumor surgery were randomly divided in two groups. In group D (n=15), dexmedetomidine was infused as a 1 μg/kg bolus dose 10 minutes before induction of anesthesia and maintained with 0.4–0.5 μg/kg/min during the operation. In group F (n=15), animals were given fentanyl 0.02 μg/kg/min as an infusion for anesthesia maintenance. At induction, fentanyl was given as a 2 μg/kg dose in group D and as a 4 μg/kg dose in group F. Hemodynamic changes, recovery times and postoperative side effects were recorded before induction, during the perioperative period and 24 hours postoperatively. Results: In group D; MAP and HR values after intubation, after skull clamp insertion and after extubation were lower than in group F (p<0.05). In group D, cerebral relaxation scores were also significantly lower. Recovery times were found to be shorter in group D as compared to group F; the same trend was observed for the supplemental opioid requirement. During the postoperative period, there was no shivering, nausea or vomiting in group D, but in group F, 3 patients complained of shivering, and 2 patients experienced nausea and vomiting. Conclusion: In our study, we found that dexmedetomidine controlled the hemodynamic changes better than fentanyl perioperatively, after extubation and during the early postoperative period. Our results suggest that that dexmedetomidine is safer and more effective in controlling hemodynamic changes during surgical stimulation than the standard agents used in neuroanesthesia. PMID:25610125

Awake Craniotomy: A New Airway Approach.

PubMed

Sivasankar, Chitra; Schlichter, Rolf A; Baranov, Dimitry; Kofke, W Andrew

2016-02-01

Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.

The procyonid social club: comparison of brain volumes in the coatimundi (Nasua nasua, N. narica), kinkajou (Potos flavus), and raccoon (Procyon lotor).

PubMed

Arsznov, Bradley M; Sakai, Sharleen T

2013-01-01

The present study investigated whether increased relative brain size, including regional brain volumes, is related to differing behavioral specializations exhibited by three member species of the family Procyonidae. Procyonid species exhibit continuums of behaviors related to social and physical environmental complexities: the mostly solitary, semiarboreal and highly dexterous raccoons (Procyon lotor); the exclusively arboreal kinkajous (Potos flavus), which live either alone or in small polyandrous family groups, and the social, terrestrial coatimundi (Nasua nasua, N. narica). Computed tomographic (CT) scans of 45 adult skulls including 17 coatimundis (9 male, 8 female), 14 raccoons (7 male, 7 female), and 14 kinkajous (7 male, 7 female) were used to create three-dimensional virtual endocasts. Endocranial volume was positively correlated with two separate measures of body size: skull basal length (r = 0.78, p < 0.01) and basicranial axis length (r = 0.45, p = 0.002). However, relative brain size (total endocranial volume as a function of body size) varied by species depending on which body size measurement (skull basal length or basicranial axis length) was used. Comparisons of relative regional brain volumes revealed that the anterior cerebrum volume consisting mainly of frontal cortex and surface area was significantly larger in the social coatimundi compared to kinkajous and raccoons. The dexterous raccoon had the largest relative posterior cerebrum volume, which includes the somatosensory cortex, in comparison to the other procyonid species studied. The exclusively arboreal kinkajou had the largest relative cerebellum and brain stem volume in comparison to the semi arboreal raccoon and the terrestrial coatimundi. Finally, intraspecific comparisons failed to reveal any sex differences, except in the social coatimundi. Female coatimundis possessed a larger relative frontal cortical volume than males. Social life histories differ in male and female coatimundis but not in either kinkajous or raccoons. This difference may reflect the differing social life histories experienced by females who reside in their natal bands, and forage and engage in antipredator behavior as a group, while males disperse upon reaching adulthood and are usually solitary thereafter. This analysis in the three procyonid species supports the comparative neurology principle that behavioral specializations correspond to an expansion of neural tissue involved in that function.

Diagnostic and prognostic value of procalcitonin for early intracranial infection after craniotomy

PubMed Central

Yu, Y.; Li, H.J.

2017-01-01

Intracranial infection is a common clinical complication after craniotomy. We aimed to explore the diagnostic and prognostic value of dynamic changing procalcitonin (PCT) in early intracranial infection after craniotomy. A prospective study was performed on 93 patients suspected of intracranial infection after craniotomy. Routine peripheral venous blood was collected on the day of admission, and C reactive protein (CRP) and PCT levels were measured. Cerebrospinal fluid (CSF) was collected for routine biochemical, PCT and culture assessment. Serum and CSF analysis continued on days 1, 2, 3, 5, 7, 9, and 11. The patients were divided into intracranial infection group and non-intracranial infection group; intracranial infection group was further divided into infection controlled group and infection uncontrolled group. Thirty-five patients were confirmed with intracranial infection after craniotomy according to the diagnostic criteria. The serum and cerebrospinal fluid PCT levels in the infected group were significantly higher than the non-infected group on day 1 (P<0.05, P<0.01). The area under curve of receiver operating characteristics was 0.803 for CSF PCT in diagnosing intracranial infection. The diagnostic sensitivity and specificity of CSF PCT was superior to other indicators. The serum and CSF PCT levels have potential value in the early diagnosis of intracranial infection after craniotomy. Since CSF PCT levels have higher sensitivity and specificity, dynamic changes in this parameter could be used for early detection of intracranial infection after craniotomy, combined with other biochemical indicators. PMID:28443989

Prenatal assessment of ventriculomegaly: an anatomical study.

PubMed

Glonek, Michał; Kedzia, Alicja; Derkowski, Wojciech

2003-07-01

The aim of the study was to analyze the development of the lateral ventricles during the 1st and 2nd trimester of fetal life using computerized image processing, and to compare the findings with the results obtained by ultrasound imaging and MRI. The material consisted of 32 fetuses from spontaneous abortions, 54-235 mm crown-rump length. After detached craniotomy, the brains were cut into axial sections; the sections were filmed with a video camera and then analyzed using specialized software In 12 analyzed brains, no significant pathological changes were observed in the cerebral hemispheres, whereas the remaining 20 (63%) demonstrated visible pathology. In 10 cases there were areas of leukomalacia, in 5 intra- and periventricular hemorrhages, and in 2 fetuses ventriculomegaly with lateral ventricular triangles over 10 mm wide (in cases of active hydrocephalus and colpocephaly). In 1 case of an 18-week-old fetus, lateral ventricular morphology typical of hydrocephalus (generalized distension) was observed with ventricular triangles 8.5 mm wide. The other 2 fetuses demonstrated developmental defects. The frontal horns were the most markedly enlarged in both cases of hydrocephalus (100%) and were semicircular, whereas after intra- and periventricular hemorrhages they were less enlarged and triangular, with the base of the triangle directed to the front and frequent significant asymmetry. The shape of the ventricular system, including that of the frontal horns, is important in the diagnostics of fetal CNS.

Awake craniotomy and multilingualism: language testing during anaesthesia for awake craniotomy in a bilingual patient.

PubMed

Costello, T G

2014-08-01

An awake craniotomy for epilepsy surgery is presented where a bilingual patient post-operatively reported temporary aphasia of his first language (Spanish). This case report discusses the potential causes for this clinical presentation and methods to prevent the occurrence of this in future patients undergoing this form of surgery. Copyright © 2014 Elsevier Ltd. All rights reserved.

P10.05 Establishment of team work awake craniotomy: clinical experience in Taiwan

PubMed Central

Chen, P.; Chang, W.; Chao, Y.; Toh, C.; Wei, K.

2017-01-01

Abstract Introduction: Awake craniotomy provides the opportunity to maximize both extent of resection and preservation of neurological function. Serial preoperative and postoperative neurobehavial evaluation, magnetic resonance image examination and intraoperative task investigation need multidisciplinary experts to cooperate. Materials and Methods: From 2013, we gradually establish our team for awake craniotomy. Patient who had brain tumor with the symptom of aphasia or hemiparesis and are willing to cooperate would be entered the protocol of awake craniotomy. Patients would receive complete preoperative neurobehavial examination by psychologists and speech therapists and magnetic resonance image included diffuse tensor image. During operation, Patients went through asleep-awake-asleep anesthetic techniques. Direct electric stimulation was used for both cortical and subcortical mapping. Navigation included information of lesion and important fiber tract guided the direction of excision. Rehabilitation doctor performed the tasks and decided the positive response caused by stimulation or excisional procedure. After operation, post-operative image and neurobehavial examination would be performed within one week, 3 months, 6 months and one year later Results: We scheduled awake craniotomy on almost every Tuesday. In recent 89 patients who received awake craniotomy, Twenty-five participants with recurrent tumor underwent the operation. Seven patients received twice and one patient received three times of awake craniotomy. Two patients had controllable intraoperative seizure attack. Early termination of awake status was found in two patients due to general discomfort. Patients with modest preoperative performance status still benefit from the operation. Neurobehavioral functions improved over time and some specific feature correlate to certain aspect of quality of life. The grading of tumor and the extension of resection influence the recovery of neurobehavioral functions and progression free survival considerably. Conclusions: Awake craniotomy is a feasible and effective way to improve not only patient`s survival rate but also quality of life. A team with neurosurgeon, rehabilitation doctor, speech therapist, psychologist, anesthesiologist, nurses and other specialist is important to improve the quality of clinical care for patient who received awake craniotomy. This study is supported by Chang Gung Memorial Hospital with grant number: CMRPG3D0243

Penetrating gunshots to the head and lack of immediate incapacitation. II. Review of case reports.

PubMed

Karger, B

1995-01-01

Because of the enhanced intracranial tissue disruption (see companion paper) and the functional significance of the central nervous system, penetrating gunshot wounds of the head commonly result in immediate incapacitation. However, in the last century numerous publications reported sustained capability to act following penetrating gunshot wounds of the head. These are reviewed. A large number of case reports had to be excluded from re-examination because of doubtful capability to act or lack of morphological documentation. There remained 53 case reports from 42 sources for systematic analysis. Favourable conditions for sustained capability to act are present in cases where the additional wounding resulting from the special wound ballistic qualities of the head (see companion paper) are minimized. Thus, more than 70% of the guns used fired slow and lightweight bullets: 6.35 mm Browning, .22 rimfire or extremely ineffective projectiles (ancient, inappropriate or selfmade). A centre-fire rifle or a shotgun from close range were never employed in cases involving intracerebral tracts. A coincidence of several lucky circumstances made sustained capability to act possible in two cases of military centrefire rifle bullets passing longitudinally between the frontal lobes without direct contact with brain tissue. Only two large handguns resulting in intracerebral wounding were used: one firing a .38 special bullet, which solely wounded the base of the right temporal lobe and one firing a .45 lead bullet, which seriously injured the left frontal lobe but whose trajectory was limited to the anterior fossa of the skull. Of the trajectories, 28% were outside the neurocranium. At least 70% of the craniocerebral tracts passed above the anterior fossa of the skull, wounding the frontal parts of the brain. Apart from a neurophysiological approach, this preference can be explained by the fact that the base of the anterior cranial fossa and the sella turcica area serve as a bony barrier protecting the parts of the brain located in its "shadow"' relative to the trajectory against cavitational tissue displacement and associated overpressures. This is particularly true of the brain stem. Intracerebral trajectories not located above the anterior fossa were caused by slow and lightweight bullets preferring one temporal lobe. Additionally, one parietal and one occipital lobe were each injured once by a very ineffective projectile and by a 7.65-mm bullet reduced in velocity. Not a single case of injury to the brain stem, the diencephalon, the cerebellum or major paths of motor conduction and only one grazing shot of the anterior parts of the nucleus caudatus (basal ganglia) were described. Morphological signs of high intracranial pressure peaks (cortical contusion zones, indirect skull fractures, perivascular haemorrhages) and secondary missiles were poorly documented. It is suggested that these findings are at least very rare and not obvious in cases of sustained capability to act.

Skull trepanation in the Bismarck archipelago.

PubMed

Watters, David A K

2007-01-01

Skull trepanation is an ancient art and has been recognized in many, if not most, primitive societies. Papua New Guinea came into contact with Europeans in the late 1800s and therefore it was possible for the art to be documented at a time when cranial surgery in Europe was still in its infancy. A reviewof published articles and accounts of those who observed skull trepanation or spoke to those who had. Review of a video of trepanation as practised today in Lihir. Richard Parkinson was a trader turned amateur anthropologist who was able to observe the surgical procedure being practised in Blanche Bay (New Britain). Trepanation was also witnessed by Rev. J.A. Crump in the Duke of Yorks. In New Britain the operation was performed for trauma but in New Ireland it was also employed on conscious patients for epilepsy or severe headache, particularly in the first five years of life. There was, however, a tendency to operate on frontal depressed and open fractures, rather than temporoparietal ones. Once the decision to operate was made the wound was irrigated in coconut juice and this was also used to wash the hands of the surgeon. Anaesthesia was not required as the traumatized patient was unconscious. The procedure is described and the tools included local materials such as obsidian, shark's tooth, a sharpened shell, rattan, coconut shell and bamboo. Of particular interest is the observation of brain pulsations and their relationship to a successful outcome. The outcomes were good, in that 70% of patients were thought to survive, contrasting with a 75% mortality for cranial surgery in London in the 1870s. There is supporting evidence in that many trepanned skulls show evidence of healing and life long after the procedure was completed. Other societies have reported similar survival rates. The good outcomes may have been due to wise case selection as well as a high level of surgical skill following sound principles of wound debridement without necessarily being able to drain a haematoma.

Forward and inverse effects of the complete electrode model in neonatal EEG

PubMed Central

Lew, S.; Wolters, C. H.

2016-01-01

This paper investigates finite element method-based modeling in the context of neonatal electroencephalography (EEG). In particular, the focus lies on electrode boundary conditions. We compare the complete electrode model (CEM) with the point electrode model (PEM), which is the current standard in EEG. In the CEM, the voltage experienced by an electrode is modeled more realistically as the integral average of the potential distribution over its contact surface, whereas the PEM relies on a point value. Consequently, the CEM takes into account the subelectrode shunting currents, which are absent in the PEM. In this study, we aim to find out how the electrode voltage predicted by these two models differ, if standard size electrodes are attached to a head of a neonate. Additionally, we study voltages and voltage variation on electrode surfaces with two source locations: 1) next to the C6 electrode and 2) directly under the Fz electrode and the frontal fontanel. A realistic model of a neonatal head, including a skull with fontanels and sutures, is used. Based on the results, the forward simulation differences between CEM and PEM are in general small, but significant outliers can occur in the vicinity of the electrodes. The CEM can be considered as an integral part of the outer head model. The outcome of this study helps understanding volume conduction of neonatal EEG, since it enlightens the role of advanced skull and electrode modeling in forward and inverse computations. NEW & NOTEWORTHY The effect of the complete electrode model on electroencephalography forward and inverse computations is explored. A realistic neonatal head model, including a skull structure with fontanels and sutures, is used. The electrode and skull modeling differences are analyzed and compared with each other. The results suggest that the complete electrode model can be considered as an integral part of the outer head model. To achieve optimal source localization results, accurate electrode modeling might be necessary. PMID:27852731

Reconstructing the Life of an Unknown (ca. 500 Years-Old South American Inca) Mummy – Multidisciplinary Study of a Peruvian Inca Mummy Suggests Severe Chagas Disease and Ritual Homicide

PubMed Central

Panzer, Stephanie; Peschel, Oliver; Haas-Gebhard, Brigitte; Bachmeier, Beatrice E.; Pusch, Carsten M.; Nerlich, Andreas G.

2014-01-01

The paleopathological, paleoradiological, histological, molecular and forensic investigation of a female mummy (radiocarbon dated 1451–1642 AD) provides circumstantial evidence for massive skull trauma affecting a young adult female individual shortly before death along with chronic infection by Trypanosoma cruzi (Chagas disease). The mummy (initially assumed to be a German bog body) was localized by stable isotope analysis to South America at/near the Peruvian/Northern Chilean coast line. This is further supported by New World camelid fibers attached to her plaits, typical Inca-type skull deformation and the type of Wormian bone at her occiput. Despite an only small transverse wound of the supraorbital region computed tomography scans show an almost complete destruction of face and frontal skull bones with terrace-like margins, but without evidence for tissue reaction. The type of destruction indicates massive blunt force applied to the center of the face. Stable isotope analysis indicates South American origin: Nitrogen and hydrogen isotope patterns indicate an extraordinarily high marine diet along with C4-plant alimentation which fits best to the coastal area of Pacific South America. A hair strand over the last ten months of her life indicates a shift to a more “terrestric” nutrition pattern suggesting either a move from the coast or a change in her nutrition. Paleoradiology further shows extensive hypertrophy of the heart muscle and a distended large bowel/rectum. Histologically, in the rectum wall massive fibrosis alternates with residual smooth muscle. The latter contains multiple inclusions of small intracellular parasites as confirmed by immunohistochemical and molecular ancient DNA analysis to represent a chronic Trypanosoma cruzi infection. This case shows a unique paleopathological setting with massive blunt force trauma to the skull nurturing the hypothesis of a ritual homicide as previously described in South American mummies in an individual that suffered from severe chronic Chagas disease. PMID:24586848

Surgical Management of Dural Arteriovenous Fistula After Craniotomy: Case Report and Review of Literature.

PubMed

Pabaney, Aqueel H; Robin, Adam M; Basheer, Azam; Malik, Ghaus

2016-05-01

Development of dural arteriovenous fistula (dAVF) with cortical venous drainage at the site of previous craniotomy is a rare manifestation of nontraumatic subarachnoid hemorrhage (SAH). The authors present a case of postcraniotomy dAVF formation and discuss plausible underlying mechanisms of fistula formation and treatment options as well as review the literature. A 62-year-old man, who had undergone craniotomy 2 decades previously, presented with SAH. Workup revealed a low-flow dAVF with leptomeningeal venous drainage at the posterior margin of the craniotomy. Surgical resection of fistula was undertaken that resulted in cure. Spontaneous SAH in patients with a previous history of an intracranial procedure (e.g., craniotomy, ventriculostomy) should prompt detailed imaging evaluation. In the absence of vascular disease, meticulous review of the angiogram must be undertaken to rule out dAVF at the procedure site and it should be treated definitively. Copyright © 2016 Elsevier Inc. All rights reserved.

Awake craniotomy

PubMed Central

Bajunaid, Khalid M.; Ajlan, Abdulrazag M.

2015-01-01

Objective: To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. Methods: We carried out a qualitative descriptive survey of patients’ experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. Results: Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. Conclusion: Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations. PMID:26166593

Awake craniotomy. A patient`s perspective.

PubMed

Bajunaid, Khalid M; Ajlan, Abdulrazag M

2015-07-01

To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. We carried out a qualitative descriptive survey of patients` experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Infections in patients undergoing craniotomy: risk factors associated with post-craniotomy meningitis.

PubMed

Kourbeti, Irene S; Vakis, Antonis F; Ziakas, Panayiotis; Karabetsos, Dimitris; Potolidis, Evangelos; Christou, Silvana; Samonis, George

2015-05-01

OBJECT The authors performed a prospective study to define the prevalence and microbiological characteristics of infections in patients undergoing craniotomy and to clarify the risk factors for post-craniotomy meningitis. METHODS Patients older than 18 years who underwent nonstereotactic craniotomies between January 2006 and December 2008 were included. Demographic, clinical, laboratory, and microbiological data were systemically recorded. Patient characteristics, craniotomy type, and pre- and postoperative variables were evaluated as risk factors for meningitis RESULTS Three hundred thirty-four procedures were analyzed (65.6% involving male patients). Traumatic brain injury was the most common reason for craniotomy. Almost 40% of the patients developed at least 1 infection. Ventilator-associated pneumonia (VAP) was the most common infection recorded (22.5%) and Acinetobacter spp. were isolated in 44% of the cases. Meningitis was encountered in 16 procedures (4.8%), and CSF cultures were positive for microbial growth in 100% of these cases. Gram-negative pathogens (Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Enterobacter cloaceae, Proteus mirabilis) represented 88% of the pathogens. Acinetobacter and Klebsiella spp. demonstrated a high percentage of resistance in several antibiotic classes. In multivariate analysis, the risk for meningitis was independently associated with perioperative steroid use (OR 11.55, p = 0.005), CSF leak (OR 48.03, p < 0.001), and ventricular drainage (OR 70.52, p < 0.001). CONCLUSIONS Device-related postoperative communication between the CSF and the environment, CSF leak, and perioperative steroid use were defined as risk factors for meningitis in this study. Ventilator-associated pneumonia was the most common infection overall. The offending pathogens presented a high level of resistance to several antibiotics.

Craniotomy: true sham for traumatic brain injury, or a sham of a sham?

PubMed

Cole, Jeffrey T; Yarnell, Angela; Kean, William S; Gold, Eric; Lewis, Bobbi; Ren, Ming; McMullen, David C; Jacobowitz, David M; Pollard, Harvey B; O'Neill, J Timothy; Grunberg, Neil E; Dalgard, Clifton L; Frank, Joseph A; Watson, William D

2011-03-01

Abstract Neurological dysfunction after traumatic brain injury (TBI) is caused by both the primary injury and a secondary cascade of biochemical and metabolic events. Since TBI can be caused by a variety of mechanisms, numerous models have been developed to facilitate its study. The most prevalent models are controlled cortical impact and fluid percussion injury. Both typically use "sham" (craniotomy alone) animals as controls. However, the sham operation is objectively damaging, and we hypothesized that the craniotomy itself may cause a unique brain injury distinct from the impact injury. To test this hypothesis, 38 adult female rats were assigned to one of three groups: control (anesthesia only); craniotomy performed by manual trephine; or craniotomy performed by electric dental drill. The rats were then subjected to behavioral testing, imaging analysis, and quantification of cortical concentrations of cytokines. Both craniotomy methods generate visible MRI lesions that persist for 14 days. The initial lesion generated by the drill technique is significantly larger than that generated by the trephine. Behavioral data mirrored lesion volume. For example, drill rats have significantly impaired sensory and motor responses compared to trephine or naïve rats. Finally, of the seven tested cytokines, KC-GRO and IFN-γ showed significant increases in both craniotomy models compared to naïve rats. We conclude that the traditional sham operation as a control confers profound proinflammatory, morphological, and behavioral damage, which confounds interpretation of conventional experimental brain injury models. Any experimental design incorporating "sham" procedures should distinguish among sham, experimentally injured, and healthy/naïve animals, to help reduce confounding factors.

Technical Aspects of Awake Craniotomy with Mapping for Brain Tumors in a Limited Resource Setting.

PubMed

Leal, Rafael Teixeira Magalhaes; Barcellos, Bruno Mendonça; Landeiro, Jose Alberto

2018-05-01

Brain tumor surgery near or within eloquent regions is increasingly common and is associated with a high risk of neurologic injury. Awake craniotomy with mapping has been shown to be a valid method to preserve neurologic function and increase the extent of resection. However, the technique used varies greatly among centers. Most count on professionals such as neuropsychologists, speech therapists, neurophysiologists, or neurologists to help in intraoperative patient evaluation. We describe our technique with the sole participation of neurosurgeons and anesthesiologists. A retrospective review of 19 patients who underwent awake craniotomies for brain tumors between January 2013 and February 2017 at a tertiary university hospital was performed. We sought to identify and describe the most critical stages involved in this surgery as well as show the complications associated with our technique. Preoperative preparation, positioning, anesthesia, brain mapping, resection, and management of seizures and pain were stages deemed relevant to the accomplishment of an awake craniotomy. Sixteen percent of the patients developed new postoperative deficit. Seizures occurred in 24%. None led to awake craniotomy failure. We provide a thorough description of the technique used in awake craniotomies with mapping used in our institution, where the intraoperative patient evaluation is carried out solely by neurosurgeons and anesthesiologists. The absence of other specialized personnel and equipment does not necessarily preclude successful mapping during awake craniotomy. We hope to provide helpful information for those who wish to offer function-guided tumor resection in their own centers. Copyright © 2018 Elsevier Inc. All rights reserved.

Development of a safe and pragmatic awake craniotomy program at Maine Medical Center.

PubMed

Rughani, Anand I; Rintel, Theodor; Desai, Rajiv; Cushing, Deborah A; Florman, Jeffrey E

2011-01-01

Awake craniotomy offers an excellent means of performing intraoperative mapping and optimizing surgical resection of brain tumors. Awake craniotomy relies on a strong collaboration between anesthesiologists, neurosurgeons, and operating room staff. The authors recently introduced awake craniotomy for tumor resection at the Maine Medical Center and propose that it can be performed safely, effectively, and efficiently in a high-volume community hospital. We describe a practical approach to performing awake craniotomy involving streamlined anesthetic protocols and simplified intraoperative testing parameters in a carefully selected group of patients. Our first 25 patients are retrospectively reviewed with particular attention to the anesthetic protocol, the extent of resection, the operative time, post-operative complications, the length of hospitalization, and their functional status at follow-up. The authors established an anesthetic protocol based primarily on midazolam, fentanyl, propofol, and local anesthetic. The authors note that all but one patient was able to tolerate the awake procedure. Gross total resection was achieved in nearly 80% of patients with a glial tumor. Operative time was short, averaging 159 minutes of entire anesthesia care. Length of stay averaged 3.7 days. Persistent new post-operative deficits were noted in 2 of 25 patients. There was no substantial difference in total hospital charges for patients undergoing awake craniotomy when compared to a matched historical control. With attention focused on patient selection and a streamlined anesthetic protocol, the authors were able to successfully implement an awake craniotomy protocol in a community setting with satisfying results, including low operative morbidity, short operative times, low anesthetic complications, and excellent patient tolerance.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases.

PubMed

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Dash, Hari Hara; Bithal, Parmod Kumar; Chandra, P Sarat

2015-05-01

The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days). 'Conscious sedation' was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases

PubMed Central

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Dash, Hari Hara; Bithal, Parmod Kumar; Chandra, P Sarat

2015-01-01

Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1–14 days) and mean hospital stay was 7.0 ± 5.0 day (3–30 days). Conclusions: ‘Conscious sedation’ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure. PMID:26019355

Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis.

PubMed

Motoyama, Yasushi; Nakajima, Tsukasa; Takamura, Yoshiaki; Nakazawa, Tsutomu; Wajima, Daisuke; Takeshima, Yasuhiro; Matsuda, Ryosuke; Tamura, Kentaro; Yamada, Shuichi; Yokota, Hiroshi; Nakagawa, Ichiro; Nishimura, Fumihiko; Park, Young-Su; Nakamura, Mitsutoshi; Nakase, Hiroyuki

2018-06-08

OBJECTIVE Lumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall. METHODS Included were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared. RESULTS Brain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004). CONCLUSIONS Brain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Rapid Spontaneous Redistribution of Acute Epidural Hematoma : Case Report and Literature Review

PubMed Central

Eom, Ki Seong; Park, Jong Tae; Kim, Tae Young

2009-01-01

Acute epidural hematoma (AEDH) occurring as a result of traumatic head injury constitutes one of the most critical emergencies in neurosurgery. However, there are only several reports that show the rapid disappearance of AEDH without surgical intervention. We suggest redistribution of hematoma through the overlying skull fractures as the mechanism of rapid disappearance of AEDH. A 13-year-old female fell from a height of about 2 m and presented with mild headache. A computed tomography (CT) scan performed 4 hours after the injury revealed an AEDH with an overlying fracture in the right temporal region and acute small hemorrhagic contusion in the left frontal region. A repeat CT scan 16 hours after injury revealed that the AEDH had almost completely disappeared and showed an increase in the epicranial hematoma. The patient was discharged 10 days after injury with no neurological deficits. This case is characterized by the rapid disappearance of an AEDH associated with an overlying skull fracture. We believe that the rapid disappearance of the AEDH is due to the redistribution of the hematoma, rather than its resolution or absorption, and fracture plays a key role in this process. PMID:19274119

Vibration characteristics of bone conducted sound in vitro.

PubMed

Stenfelt, S; Håkansson, B; Tjellström, A

2000-01-01

A dry skull added with damping material was used to investigate the vibratory pattern of bone conducted sound. Three orthogonal vibration responses of the cochleae were measured, by means of miniature accelerometers, in the frequency range 0.1-10 kHz. The exciter was attached to the temporal, parietal, and frontal bones, one at the time. In the transmission response to the ipsilateral cochlea, a profound low frequency antiresonance (attenuation) was found, verified psycho-acoustically, and shown to yield a distinct lateralization effect. It was also shown that, for the ipsilateral side, the direction of excitation coincides with that of maximum response. At the contralateral cochlea, no such dominating response direction was found for frequencies above the first skull resonance. An overall higher response level was achieved, for the total energy transmission in general and specifically for the direction of excitation, at the ipsilateral cochlea when the transducer was attached to the excitation point closest to the cochlea. The transranial attenuation was found to be frequency dependent, with values from -5 to 10 dB for the energy transmission and -30 to 40 dB for measurements in a single direction, with a tendency toward higher attenuation at the higher frequencies.

Malocclusions in a juvenile medieval skull material.

PubMed

Larsson, E

1983-01-01

From a mostly medieval skull material--the "Schreiner collections" in Oslo--juvenile crania were selected as follows: Group A: Crania with complete and intact primary dentition. n = 20. Group B: Crania with early mixed dentition. Incisors only erupted or under eruption. n = 47. Group C: Crania with late mixed dentition. n = 14. The author recorded visually: Sagittal and transversal dental relation, frontal dental contact, anterior cross-bite, rotation and crowding. There was good basal stability. Sagittally 1 moderately postnormal dentition was recorded, transversally there were no anomalies. Slight anterior cross-bite was recorded in 1 case, anterior cross-bite of one and two lateral incisors respectively in 2 others, and tête-à-tête contact in 3 cases. Crowding was recorded in 6 cases, in one of them being general, in the others located solely in the mandibular incisor segment. Broken contact and more or less pronounced rotation occurred in these dentitions. Rotation was also recorded in 2 other cases. The prevalence of malocclusions of the type that can be related to continuing finger-sucking or sucking of dummylike objects was very low in this material. This observation prompted the author to discuss a hypothesis concerning the aetiology of dummy- and finger-sucking habits.

Trauma of the midface

PubMed Central

Kühnel, Thomas S.; Reichert, Torsten E.

2015-01-01

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair. PMID:26770280

Out of Africa: modern human origins special feature: middle and later Pleistocene hominins in Africa and Southwest Asia.

PubMed

Rightmire, G Philip

2009-09-22

Approximately 700,000 years ago, Homo erectus in Africa was giving way to populations with larger brains accompanied by structural adjustments to the vault, cranial base, and face. Such early Middle Pleistocene hominins were not anatomically modern. Their skulls display strong supraorbital tori above projecting faces, flattened frontals, and less parietal expansion than is the case for Homo sapiens. Postcranial remains seem also to have archaic features. Subsequently, some groups evolved advanced skeletal morphology, and by ca. 200,000 years ago, individuals more similar to recent humans are present in the African record. These fossils are associated with Middle Stone Age lithic assemblages and, in some cases, Acheulean tools. Crania from Herto in Ethiopia carry defleshing cutmarks and superficial scoring that may be indicative of mortuary practices. Despite these signs of behavioral innovation, neither the Herto hominins, nor others from Late Pleistocene sites such as Klasies River in southern Africa and Skhūl/Qafzeh in Israel, can be matched in living populations. Skulls are quite robust, and it is only after approximately 35,000 years ago that people with more gracile, fully modern morphology make their appearance. Not surprisingly, many questions concerning this evolutionary history have been raised. Attention has centered on systematics of the mid-Pleistocene hominins, their paleobiology, and the timing of dispersals that spread H. sapiens out of Africa and across the Old World. In this report, I discuss structural changes characterizing the skulls from different time periods, possible regional differences in morphology, and the bearing of this evidence on recognizing distinct species.

Head injury assessment of non-lethal projectile impacts: A combined experimental/computational method.

PubMed

Sahoo, Debasis; Robbe, Cyril; Deck, Caroline; Meyer, Frank; Papy, Alexandre; Willinger, Remy

2016-11-01

The main objective of this study is to develop a methodology to assess this risk based on experimental tests versus numerical predictive head injury simulations. A total of 16 non-lethal projectiles (NLP) impacts were conducted with rigid force plate at three different ranges of impact velocity (120, 72 and 55m/s) and the force/deformation-time data were used for the validation of finite element (FE) NLP. A good accordance between experimental and simulation data were obtained during validation of FE NLP with high correlation value (>0.98) and peak force discrepancy of less than 3%. A state-of-the art finite element head model with enhanced brain and skull material laws and specific head injury criteria was used for numerical computation of NLP impacts. Frontal and lateral FE NLP impacts to the head model at different velocities were performed under LS-DYNA. It is the very first time that the lethality of NLP is assessed by axonal strain computation to predict diffuse axonal injury (DAI) in NLP impacts to head. In case of temporo-parietal impact the min-max risk of DAI is 0-86%. With a velocity above 99.2m/s there is greater than 50% risk of DAI for temporo-parietal impacts. All the medium- and high-velocity impacts are susceptible to skull fracture, with a percentage risk higher than 90%. This study provides tool for a realistic injury (DAI and skull fracture) assessment during NLP impacts to the human head. Copyright © 2016 Elsevier Ltd. All rights reserved.

Analysis of the upper massif of the craniofacial with the radial method – practical use

PubMed Central

Lepich, Tomasz; Dąbek, Józefa; Stompel, Daniel; Gielecki, Jerzy S.

2011-01-01

Introduction The analysis of the upper massif of the craniofacial (UMC) is widely used in many fields of science. The aim of the study was to create a high resolution computer system based on a digital information record and on vector graphics, that could enable dimension measuring and evaluation of craniofacial shape using the radial method. Material and methods The study was carried out on 184 skulls, in a good state of preservation, from the early middle ages. The examined skulls were fixed into Molisson's craniostat in the author's own modification. They were directed in space towards the Frankfurt plane and photographed in frontal norm with a digital camera. The parameters describing the plane and dimensional structure of the UMC and orbits were obtained thanks to the computer analysis of the function recordings picturing the craniofacial structures and using software combining raster graphics with vector graphics. Results It was compared mean values of both orbits separately for male and female groups. In female skulls the comparison of the left and right side did not show statistically significant differences. In male group, higher values were observed for the right side. Only the circularity index presented higher values for the left side. Conclusions Computer graphics with the software used for analysing digital pictures of UMC and orbits increase the precision of measurements as well as the calculation possibilities. Recognition of the face in the post mortem examination is crucial for those working on identification in anthropology and criminology laboratories. PMID:22291834

Radiomorphometric analysis of frontal sinus for sex determination.

PubMed

Verma, Saumya; Mahima, V G; Patil, Karthikeya

2014-09-01

Sex determination of unknown individuals carries crucial significance in forensic research, in cases where fragments of skull persist with no likelihood of identification based on dental arch. In these instances sex determination becomes important to rule out certain number of possibilities instantly and helps in establishing a biological profile of human remains. The aim of the study is to evaluate a mathematical method based on logistic regression analysis capable of ascertaining the sex of individuals in the South Indian population. The study was conducted in the department of Oral Medicine and Radiology. The right and left areas, maximum height, width of frontal sinus were determined in 100 Caldwell views of 50 women and 50 men aged 20 years and above, with the help of Vernier callipers and a square grid with 1 square measuring 1mm(2) in area. Student's t-test, logistic regression analysis. The mean values of variables were greater in men, based on Student's t-test at 5% level of significance. The mathematical model based on logistic regression analysis gave percentage agreement of total area to correctly predict the female gender as 55.2%, of right area as 60.9% and of left area as 55.2%. The areas of the frontal sinus and the logistic regression proved to be unreliable in sex determination. (Logit = 0.924 - 0.00217 × right area).

Nasofrontal dermoid sinus cyst: report of two cases.

PubMed

Zerris, Vasilios A; Annino, Don; Heilman, Carl B

2002-09-01

Nasofrontal dermoid sinus cysts are rare. The embryological origin, presentation, treatment, and genetic associations of two cases of these cysts are discussed. Emphasis is placed on physical findings and the importance of addressing both the intracranial and extracranial components. The first patient, a 33-year-old woman, sought care for chemical meningitis. As a child, she was differentiated from her identical twin sister by a dimple on the tip of her nose. The second patient, a 34-year-old man, sought care for new-onset seizures. Since birth, he had a dimple on the tip of his nose. As a child, he had undergone resection of a nasal cyst. Imaging studies in both patients indicated a midline anterior cranial base mass within the falx and a defect in the crista galli. Both patients underwent biorbitofrontal nasal craniotomy. A bifrontal craniotomy was performed first, then removal of the orbitonasal ridge. The dermoid and involved falx were resected. The sinus tract was followed through the crista galli and resected up to the osteocartilaginous junction in the nose. The remainder of the tract was resected via a small incision through the nares. The dura was closed primarily by mobilizing the dura along the sides of the crista galli. After surgery, both patients still possessed their sense of smell. Nasofrontal dermoid sinus cysts have a unique embryological origin. A midline basal frontal dermoid associated with a dimple on the nasal surface with or without protruding hair and sebaceous discharge is the pathognomonic presentation. It is important to address both the intracranial and extracranial component surgically. Although concomitant anomalies and familial clustering have been described, most cases are spontaneous occurrences.

The Air Force Critical Care Air Transport Team (CCATT): Using the Estimating Supplies Program (ESP) to Validate Clinical Requirements

DTIC Science & Technology

2005-04-05

categories are postsurgical cases, and represent thoracic, staged exploratory laparotomy, vascular/amputation, and craniotomy PCs for which surgical...Post Surgical Craniotomy J – Environmental Emergency E – Burns > 20% BSA K – Medical, Anaphylaxis/Asthma F – Class III and IV Hemorrhagic Shock...Amputation G – Crush/Blunt Injury K – Med, Anaphylaxis Asthma D – Post Surgical Craniotomy H – Head Injury

Spreading Depressions as Secondary Insults after Traumatic Injury to the Human Brain

DTIC Science & Technology

2012-09-01

earlier and larger craniotomies and better outcomes, despite being similar in initial injury characteristics compared to KCH patients. VCU patients also...enrolled patients with acute TBI who met the following inclusion criteria: clinical decision for craniotomy for lesion evacuation, de compression, or... craniotomies for evacuation of intracranial mass lesions or cerebral decompression, a median of 9·9 h (IQR 4·5–26·3) after trauma

The Air Force Mobile Forward Surgical Team (MFST): Using the Estimating Supplies Program to Validate Clinical Requirement

DTIC Science & Technology

2004-12-01

conducted in an abbreviated, staged manner, such as laparotomies, decompression craniotomies , vascular shunts, or amputations. The FRSS provides...Performed at MFST Abbreviated laparotomy 36.29 Vascular shunt/ligate 32.84 Amputation 12.32 Decompression craniotomy 8.98 Thoracotomy 6.35...Vascular shunt/ligations 6 33 Abbreviated laparotomy 4 22 Amputation 3 16 Decompression craniotomy 3 16 Thoracotomy 2 10 Other 3 Total 18 100

Transzygomatic approach with intraoperative neuromonitoring for resection of middle cranial fossa tumors.

PubMed

Son, Byung Chul; Lee, Sang Won; Kim, Sup; Hong, Jae Taek; Sung, Jae Hoon; Yang, Seung-Ho

2012-02-01

The authors reviewed the surgical experience and operative technique in a series of 11 patients with middle fossa tumors who underwent surgery using the transzygomatic approach and intraoperative neuromonitoring (IOM) at a single institution. This approach was applied to trigeminal schwannomas (n = 3), cavernous angiomas (n = 3), sphenoid wing meningiomas (n = 3), a petroclival meningioma (n = 1), and a hemangiopericytoma (n = 1). An osteotomy of the zygoma, a low-positioned frontotemporal craniotomy, removal of the remaining squamous temporal bone, and extradural drilling of the sphenoid wing made a flat trajectory to the skull base. Total resection was achieved in 9 of 11 patients. Significant motor pathway damage can be avoided using a change in motor-evoked potentials as an early warning sign. Four patients experienced cranial nerve palsies postoperatively, even though free-running electromyography of cranial nerves showed normal responses during the surgical procedure. A simple transzygomatic approach provides a wide surgical corridor for accessing the cavernous sinus, petrous apex, and subtemporal regions. Knowledge of the middle fossa structures is essential for anatomic orientation and avoiding injuries to neurovascular structures, although a neuronavigation system and IOM helps orient neurosurgeons.

[Peroperative risks in cerebral aneurysm surgery].

PubMed

Mustaki, J P; Bissonnette, B; Archer, D; Boulard, G; Ravussin, P

1996-01-01

The perioperative complications associated with cerebral aneurysm surgery require a specific anaesthetic management. Four major perioperative accidents are discussed in this review. The anaesthetic and surgical management in case of rebleeding subsequent to the re-rupture of the aneurysm is mainly prophylactic. It includes haemodynamic stability assurance, maintenance of mean arterial pressure (MAP) between 80-90 mmHg during stimulation of the patient such as endotracheal intubation, application of the skull-pin head-holder, incision, and craniotomy. The aneurysmal transmural pressure should be adequately maintained by avoiding an aggressive decrease of intracranial pressure. Once the skull is open, the brain must be kept slack in order to decrease pressure under the retractors and avoid the risks of stretching and tearing of the adjacent vessels. If, despite these precautions, the aneurysm ruptures again. MAP should be decreased to 60 mmHg and the brain rendered more slack, in order to allow direct clipping of the aneurysm, or temporary clipping of the adjacent vessels. The optimal agents in this situation are isoflurane (which decreases CMRO2), intravenous anaesthetic agents (inspite their negative inotropic effect, they may potentially protect the brain) and sodium nitroprusside. Vasospasm occurs usually between the 3rd and the 7th day after subarachnoid haemorrhage. It may be seen peroperatively. The optimal treatment, as well as prophylaxis, is moderate controlled hypertension (MAP > 100 mmHg), associated with hypervolaemia and haemodilution, the so-called triple H therapy, with strict control of the filling pressures. Other beneficial therapies are calcium antagonists (nimodipine and nicardipine), the removal of the blood accumulated around the brain and in the cisternae, and possibly local administration of papaverine. Abrupt MAP increases are controlled in order to maintain adequate aneurysmal transmural pressure. Beta-blockers, local anaesthetics administered locally or intravenously, a carefully titrated level of anaesthesia, a maintained volaemia play a protective role. Cerebral oedema is sometimes already present at the opening of the skull or may arise later, due to a high pressure under the retractors, to the surgical manipulations of the brain or to brain ischaemia subsequent to temporary clipping. Its treatment is aggressive, with intravenous agents, mannitol, deep hypocapnia and/or lumbar drainage. Prophylaxis, according to the "brain homeostasis concept", is the preferred method to avoid these four peroperative accidents. It includes normal blood volume, normoglycaemia, moderate hypocapnia, normotension, soft manipulation of the brain and optimal brain relaxation.

Spreading Depolarizations of Cerebral Cortex After Brain Injury: Mechanism of Injury Progression and Relevance to Military Neurotrauma

DTIC Science & Technology

2006-11-01

sustained penetrating brain injury (PBI). Emergency craniotomies are performed to treat these severe injuries in theater, sometimes on a daily...after craniotomy surgery. ECoG recordings were made subsequently for 1-10 days. CSD was identified by rapidly developing depression of ECoG amplitude...treat patients with moderate-to-severe TBI provides the opportunity to monitor for CSD by ECoG recordings. In these cases, craniotomy is performed as

Accuracy of frame-based stereotactic depth electrode implantation during craniotomy for subdural grid placement.

PubMed

Munyon, Charles N; Koubeissi, Mohamad Z; Syed, Tanvir U; Lüders, Hans O; Miller, Jonathan P

2013-01-01

Frame-based stereotaxy and open craniotomy may seem mutually exclusive, but invasive electrophysiological monitoring can require broad sampling of the cortex and precise targeting of deeper structures. The purpose of this study is to describe simultaneous frame-based insertion of depth electrodes and craniotomy for placement of subdural grids through a single surgical field and to determine the accuracy of depth electrodes placed using this technique. A total of 6 patients with intractable epilepsy underwent placement of a stereotactic frame with the center of the planned cranial flap equidistant from the fixation posts. After volumetric imaging, craniotomy for placement of subdural grids was performed. Depth electrodes were placed using frame-based stereotaxy. Postoperative CT determined the accuracy of electrode placement. A total of 31 depth electrodes were placed. Mean distance of distal electrode contact from the target was 1.0 ± 0.15 mm. Error was correlated to distance to target, with an additional 0.35 mm error for each centimeter (r = 0.635, p < 0.001); when corrected, there was no difference in accuracy based on target structure or method of placement (prior to craniotomy vs. through grid, p = 0.23). The described technique for craniotomy through a stereotactic frame allows placement of subdural grids and depth electrodes without sacrificing the accuracy of a frame or requiring staged procedures.

The floating anchored craniotomy

PubMed Central

Gutman, Matthew J.; How, Elena; Withers, Teresa

2017-01-01

Background: The “floating anchored” craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching. Methods: The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided. Results: From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages. Conclusions: Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy. PMID:28713633

The legacy of Hephaestus: the first craniotomy.

PubMed

Brasiliense, Leonardo Bc; Safavi-Abbasi, Sam; Crawford, Neil R; Spetzler, Robert F; Theodore, Nicholas

2010-10-01

Hephaestus is best known as the Greek god of metalworking, fire, and fine arts. As the only Olympian deity not endowed with physical perfection, he has been considered misfortunate among the Olympians. However, textual analysis of his myths reveals that Hephaestus was highly regarded by Greeks for his manual skills and intelligence. Furthermore, one of the myths about Hephaestus indicates that he performed the first recorded craniotomy. This text asserts that Hephaestus intentionally performed the craniotomy to remove a mass growing inside Zeus' head, thereby relieving him of an excruciating headache. The successful craniotomy resulted in the birth of the goddess Athena. From a neurosurgical perspective, the story is allegorical. Nonetheless, it represents the surgical management of intracranial ailments, which is thought to have been reported in Greece centuries later by Hippocrates.

[Awake craniotomy].

PubMed

Kobyakov, G L; Lubnin, A Yu; Kulikov, A S; Gavrilov, A G; Goryaynov, S A; Poddubskiy, A A; Lodygina, K S

2016-01-01

Awake craniotomy is a neurosurgical intervention aimed at identifying and preserving the eloquent functional brain areas during resection of tumors located near the cortical and subcortical language centers. This article provides a review of the modern literature devoted to the issue. The anatomical rationale and data of preoperative functional neuroimaging, intraoperative electrophysiological monitoring, and neuropsychological tests as well as the strategy of active surgical intervention are presented. Awake craniotomy is a rapidly developing technique aimed at both preserving speech and motor functions and improving our knowledge in the field of speech psychophysiology.

Flurbiprofen and hypertension but not hydroxyethyl starch are associated with post-craniotomy intracranial haematoma requiring surgery.

PubMed

Jian, M; Li, X; Wang, A; Zhang, L; Han, R; Gelb, A W

2014-11-01

Post-craniotomy intracranial haematoma is one of the most serious complications after neurosurgery. We examined whether post-craniotomy intracranial haematoma requiring surgery is associated with the non-steroidal anti-inflammatory drugs flurbiprofen, hypertension, or hydroxyethyl starch (HES). A case-control study was conducted among 42 359 patients who underwent elective craniotomy procedures at Beijing Tiantan Hospital between January 2006 and December 2011. A one-to-one control group without post-craniotomy intracranial haematoma was selected matched by age, pathologic diagnosis, tumour location, and surgeon. Perioperative blood pressure records up to the diagnosis of haematoma, the use of flurbiprofen and HES were examined. The incidence of post-craniotomy intracranial haematoma and the odds ratios for the risk factors were determined. A total of 202 patients suffered post-craniotomy intracranial haematoma during the study period, for an incidence of 0.48% (95% CI=0.41-0.55). Haematoma requiring surgery was associated with an intraoperative systolic blood pressure of >160 mm Hg (OR=2.618, 95% CI=2.084-2.723, P=0.007), an intraoperative mean blood pressure of >110 mm Hg (OR=2.600, 95% CI=2.312-3.098, P=0.037), a postoperative systolic blood pressure of >160 mm Hg (OR=2.060, 95% CI= 1.763-2.642, P=0.022), a postoperative mean blood pressure of >110 mm Hg (OR=3.600, 95% CI= 3.226-4.057, P=0.001), and the use of flurbiprofen during but not after the surgery (OR=2.256, 95% CI=2.004-2.598, P=0.005). The intraoperative infusion of HES showed no significant difference between patients who had a haematoma and those who did not. Intraoperative and postoperative hypertension and the use of flurbiprofen during surgery are risk factors for post-craniotomy intracranial haematoma requiring surgery. The intraoperative infusion of HES was not associated with a higher incidence of haematoma. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Cranial anatomy of Bellusaurus sui (Dinosauria: Eusauropoda) from the Middle-Late Jurassic Shishugou Formation of northwest China and a review of sauropod cranial ontogeny

PubMed Central

Xu, Xing

2018-01-01

Bellusaurus sui is an enigmatic sauropod dinosaur from the Middle-Late Jurassic Shishugou Formation of northwest China. Bellusaurus is known from a monospecific bonebed preserving elements from more than a dozen juvenile individuals, including numerous bones of the skull, providing rare insight into the cranial anatomy of juvenile sauropods. Here, we present a comprehensive description of the cranial anatomy of Bellusaurus, supplementing the holotypic cranial material with additional elements recovered from recent joint Sino-American field expeditions. Bellusaurus is diagnosed by several unique autapomorphies, including a neurovascular foramen piercing the ascending process of the maxilla at midheight, the frontal process of the nasal extending farther posteriorly onto the frontal than the prefrontal, and U-shaped medial and lateral notches in the posterior margin of the ventral process of the squamosal. Several features identified here, including a preantorbital opening in the maxilla, a stepped dorsal margin of the vomerine process of the pterygoid, and the partitioning of the dorsal midline endocranial fossae associated with the dural venous sinuses into anterior and posterior components by a transverse ridge of the parietal, are consistent with recent phylogenetic hypotheses that recover Bellusaurus as a basal macronarian or close relative of Neosauropoda. We review the current state of knowledge of sauropod cranial ontogeny, placing several aspects of the cranial anatomy of Bellusaurus in an ontogenetic context and providing explicit hypotheses of ontogenetic transformations that can be tested by future discoveries of ontogenetic variants of sauropod skulls. While scoring ontogenetically variable characters as unknown may help to alleviate the biasing effects of ontogeny on the phylogenetic position of juvenile specimens, we caution that this approach may remove phylogenetically informative character information, and argue that inference methods that are known to be less sensitive to homoplasy than equal weights parsimony (i.e., implied weights parsimony; Bayesian approaches) should also be employed. PMID:29868283

Effect of halo-vest components on stabilizing the injured cervical spine.

PubMed

Ivancic, Paul C; Beauchman, Naseem N; Tweardy, Lisa

2009-01-15

An in vitro biomechanical study. The objectives were to develop a new biofidelic skull-neck-thorax model capable of quantifying motion patterns of the cervical spine in the presence of a halo-vest; to investigate the effects of vest loosening, superstructure loosening, and removal of the posterior uprights; and to evaluate the ability of the halo-vest to stabilize the neck within physiological motion limits. Previous clinical and biomechanical studies have investigated neck motion with the halo-vest only in the sagittal plane or only at the injured spinal level. No previous studies have quantified three-dimensional intervertebral motion patterns throughout the injured cervical spine stabilized with the halo-vest or studied the effect of halo-vest components on these motions. The halo-vest was applied to the skull-neck-thorax model. Six osteoligamentous whole cervical spine specimens (occiput through T1 vertebra) were used that had sustained multiplanar ligamentous injuries at C3/4 through C7-T1 during a previous protocol. Flexibility tests were performed with normal halo-vest application, loose vest, loose superstructure, and following removal of the posterior uprights. Average total range of motion for each experimental condition was statistically compared (P < 0.05) with the physiologic rotation limit for each spinal level. Cervical spine snaking was observed in both the sagittal and frontal planes. The halo-vest, applied normally, generally limited average spinal motions to within average physiological limits. No significant increases in average spinal motions above physiologic were observed due to loose vest, loose superstructure, or removal of the posterior uprights. However, a trend toward increased motion at C6/7 in lateral bending was observed due to loose superstructure. The halo-vest, applied normally, effectively immobilized the cervical spine. Sagittal or frontal plane snaking of the cervical spine due to the halo-vest may reduce its immobilization capability at the upper cervical spine and cervicothoracic junction.

Classification and Microvascular Flap Selection for Anterior Cranial Fossa Reconstruction.

PubMed

Vargo, James D; Przylecki, Wojciech; Camarata, Paul J; Andrews, Brian T

2018-05-18

 Microvascular reconstruction of the anterior cranial fossa (ACF) creates difficult challenges. Reconstructive goals and flap selection vary based on the defect location within the ACF. This study evaluates the feasibility and reliability of free tissue transfer for salvage reconstruction of low, middle, and high ACF defects.  A retrospective review was performed. Reconstructions were anatomically classified as low (anterior skull base), middle (frontal bar/sinus), and high (frontal bone/soft tissue). Subjects were evaluated based on pathologic indication and goal, type of flap used, and complications observed.  Eleven flaps in 10 subjects were identified and anatomic sites included: low ( n  = 5), middle ( n  = 3), and high ( n  = 3). Eight of 11 reconstructions utilized osteocutaneous flaps including the osteocutaneous radial forearm free flap (OCRFFF) ( n  = 7) and fibula ( n  = 1). Other reconstructions included a split calvarial graft wrapped within a temporoparietal fascia free flap ( n  = 1), latissimus myocutaneous flap ( n  = 1), and rectus abdominis myofascial flap ( n  = 1). All 11 flaps were successful without microvascular compromise. No complications were observed in the high and middle ACF defect groups. Two of five flaps in the low defect group using OCRFFF flaps failed to achieve surgical goals despite demonstrating healthy flaps upon re-exploration. Complications included persistent cerebrospinal fluid leak ( n  = 1) and pneumocephalus ( n  = 1), requiring flap repositioning in one subject and a second microvascular flap in the second subject to achieve surgical goals.  In our experience, osteocutaneous flaps (especially the OCRFFF) are preferred for complete autologous reconstruction of high and middle ACF defects. Low skull base defects are more difficult to reconstruct, and consideration of free muscle flaps (no bone) should be weighed as an option in this anatomic area. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Epsilon Aminocaproic Acid Pretreatment Provides Neuroprotection Following Surgically Induced Brain Injury in a Rat Model.

PubMed

Komanapalli, Esther S; Sherchan, Prativa; Rolland, William; Khatibi, Nikan; Martin, Robert D; Applegate, Richard L; Tang, Jiping; Zhang, John H

2016-01-01

Neurosurgical procedures can damage viable brain tissue unintentionally by a wide range of mechanisms. This surgically induced brain injury (SBI) can be a result of direct incision, electrocauterization, or tissue retraction. Plasmin, a serine protease that dissolves fibrin blood clots, has been shown to enhance cerebral edema and hemorrhage accumulation in the brain through disruption of the blood brain barrier. Epsilon aminocaproic acid (EAA), a recognized antifibrinolytic lysine analogue, can reduce the levels of active plasmin and, in doing so, potentially can preserve the neurovascular unit of the brain. We investigated the role of EAA as a pretreatment neuroprotective modality in a SBI rat model, hypothesizing that EAA therapy would protect brain tissue integrity, translating into preserved neurobehavioral function. Male Sprague-Dawley rats were randomly assigned to one of four groups: sham (n = 7), SBI (n = 7), SBI with low-dose EAA, 150 mg/kg (n = 7), and SBI with high-dose EAA, 450 mg/kg (n = 7). SBI was induced by partial right frontal lobe resection through a frontal craniotomy. Postoperative assessment at 24 h included neurobehavioral testing and measurement of brain water content. Results at 24 h showed both low- and high-dose EAA reduced brain water content and improved neurobehavioral function compared with the SBI groups. This suggests that EAA may be a useful pretherapeutic modality for SBI. Further studies are needed to clarify optimal therapeutic dosing and to identify mechanisms of neuroprotection in rat SBI models.

Surgical Evacuation of Spontaneous Supratentorial Lobar Intracerebral Hemorrhage: Comparison of Safety and Efficacy of Stereotactic Aspiration, Endoscopic Surgery, and Craniotomy.

PubMed

Li, Yuqian; Yang, Ruixin; Li, Zhihong; Yang, Yanping; Tian, Bo; Zhang, Xingye; Wang, Bao; Lu, Dan; Guo, Shaochun; Man, Minghao; Yang, Yang; Luo, Tao; Gao, Guodong; Li, Lihong

2017-09-01

The safety and efficacy of craniotomy, endoscopic surgery, and stereotactic aspiration for surgical evacuation of spontaneous supratentorial lobar intracerebral hemorrhage (ICH) is yet uncertain. The present study analyzed the clinical and radiographic data from 99 patients with spontaneous supratentorial lobar ICH, retrospectively, to address this issue. Patients who underwent craniotomy, endoscopy surgery, or stereotactic aspiration were assigned to the craniotomy group (n = 31), endoscopy surgery group (n = 32), or stereotactic aspiration group (n = 36), respectively. The characteristics of all the enrolled patients at the time of admission were assimilated. Also, the therapeutic effects of the three surgical procedures were evaluated based on short-term outcomes within 30 days and long-term outcomes at 6 months after the ictus. The results showed that stereotactic aspiration and endoscopic surgery were associated with a superior clinical therapeutic effect in both short-term and long-term outcomes than craniotomy for the treatment of spontaneous supratentorial lobar ICH. Notably, severely affected patients with hematoma volume > 60 mL or Glasgow Coma Scale score 4-8 may benefit more from endoscopic surgery than the two other surgical procedures. The current findings demonstrate that both stereotactic aspiration and endoscopic surgery possess an apparent advantage over craniotomy for the evacuation of spontaneous supratentorial lobar ICH. The endoscopic surgery might be more safe and effective with higher evacuation rate, better functional neurological outcomes, and lower complication and mortality rates. Copyright © 2017 Elsevier Inc. All rights reserved.

Asleep-awake-asleep craniotomy: a comparison with general anesthesia for resection of supratentorial tumors.

PubMed

Rajan, Shobana; Cata, Juan P; Nada, Eman; Weil, Robert; Pal, Rakhi; Avitsian, Rafi

2013-08-01

The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47 mmHg versus 102.9 mmHg, p < 0.05 and emergence 84.85 mmHg versus 105 mmHg, p < 0.05). Patients in the AW group required less vasopressors intraoperatively (AW = 43% versus AS = 69%, p < 0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen. Copyright © 2013 Elsevier Ltd. All rights reserved.

Awake craniotomy for assisting placement of auditory brainstem implant in NF2 patients.

PubMed

Zhou, Qiangyi; Yang, Zhijun; Wang, Zhenmin; Wang, Bo; Wang, Xingchao; Zhao, Chi; Zhang, Shun; Wu, Tao; Li, Peng; Li, Shiwei; Zhao, Fu; Liu, Pinan

2018-06-01

Auditory brainstem implants (ABIs) may be the only opportunity for patients with NF2 to regain some sense of hearing sensation. However, only a very small number of individuals achieved open-set speech understanding and high sentence scores. Suboptimal placement of the ABI electrode array over the cochlear nucleus may be one of main factors for poor auditory performance. In the current study, we present a method of awake craniotomy to assist with ABI placement. Awake surgery and hearing test via the retrosigmoid approach were performed for vestibular schwannoma resections and auditory brainstem implantations in four patients with NF2. Auditory outcomes and complications were assessed postoperatively. Three of 4 patients who underwent awake craniotomy during ABI surgery received reproducible auditory sensations intraoperatively. Satisfactory numbers of effective electrodes, threshold levels and distinct pitches were achieved in the wake-up hearing test. In addition, relatively few electrodes produced non-auditory percepts. There was no serious complication attributable to the ABI or awake craniotomy. It is safe and well tolerated for neurofibromatosis type 2 (NF2) patients using awake craniotomy during auditory brainstem implantation. This method can potentially improve the localization accuracy of the cochlear nucleus during surgery.

A 3D morphometric follow-up analysis after frontoorbital advancement in non-syndromic craniosynostosis.

PubMed

Martini, M; Schulz, M; Röhrig, A; Nadal, J; Messing-Jünger, M

2015-10-01

Frontoorbital advancement (FOA) in patients with non-syndromic craniosynostosis mainly addresses the aesthetic and functional correction of the frontoorbital region. To help define the operative strategy and any follow-up assessments after surgical correction, objective parameters describing the critical regions of skull deformity are essential. Based on 3D morphometric analysis, new parameters for the documentation of changes of the frontoorbital bandeau were developed in a prospective study. In a prospective series, 13 children with non-syndromic craniosynostosis (seven metopic, four unilateral coronal, and two bilateral coronal) treated with frontoorbital advancement, underwent detailed morphometric and volumetric evaluation using a 3D light optical scan system (3D-Shape, Erlangen, Germany). Measurements were obtained preoperatively and at 3, 6 and 12 months postoperatively with newly developed parameters generated by cephalometric analysis software (Onyx Ceph, Image Instruments, Chemnitz, Germany). In most patients, frontoorbital advancement resulted in stable long-term results without growth inhibition and with normalization or improvement of ongoing skull development. The mean frontal angle was 145° and the frontoparietal angle 137-140°. The cephalic index was normalized or markedly improved. Head circumference and head height increased significantly (p = 0.001 and p = 0.002, respectively). These changes were confirmed in all postoperative measurements. During the 12-month follow-up period all angle parameters proved to be stable and no major impairment of normal skull growth was observed after FOA. The frontoorbital angle is a useful parameter in evaluating long-term outcome. The frontoparietal angle is important for the stability of the frontoparietal region, in which a certain growth inhibition may be observed postoperatively. Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

New head equivalent phantom for task and image performance evaluation representative for neurovascular procedures occurring in the Circle of Willis

NASA Astrophysics Data System (ADS)

Ionita, Ciprian N.; Loughran, Brendan; Jain, Amit; Swetadri Vasan, S. N.; Bednarek, Daniel R.; Levy, Elad; Siddiqui, Adnan H.; Snyder, Kenneth V.; Hopkins, L. N.; Rudin, Stephen

2012-03-01

Phantom equivalents of different human anatomical parts are routinely used for imaging system evaluation or dose calculations. The various recommendations on the generic phantom structure given by organizations such as the AAPM, are not always accurate when evaluating a very specific task. When we compared the AAPM head phantom containing 3 mm of aluminum to actual neuro-endovascular image guided interventions (neuro-EIGI) occurring in the Circle of Willis, we found that the system automatic exposure rate control (AERC) significantly underestimated the x-ray parameter selection. To build a more accurate phantom for neuro-EIGI, we reevaluated the amount of aluminum which must be included in the phantom. Human skulls were imaged at different angles, using various angiographic exposures, at kV's relevant to neuro-angiography. An aluminum step wedge was also imaged under identical conditions, and a correlation between the gray values of the imaged skulls and those of the aluminum step thicknesses was established. The average equivalent aluminum thickness for the skull samples for frontal projections in the Circle of Willis region was found to be about 13 mm. The results showed no significant changes in the average equivalent aluminum thickness with kV or mAs variation. When a uniform phantom using 13 mm aluminum and 15 cm acrylic was compared with an anthropomorphic head phantom the x-ray parameters selected by the AERC system were practically identical. These new findings indicate that for this specific task, the amount of aluminum included in the head equivalent must be increased substantially from 3 mm to a value of 13 mm.

What do cranial bones of LB1 tell us about Homo floresiensis?

PubMed

Balzeau, Antoine; Charlier, Philippe

2016-04-01

Cranial vault thickness (CVT) of Liang Bua 1, the specimen that is proposed to be the holotype of Homo floresiensis, has not yet been described in detail and compared with samples of fossil hominins, anatomically modern humans or microcephalic skulls. In addition, a complete description from a forensic and pathological point of view has not yet been carried out. It is important to evaluate scientifically if features related to CVT bring new information concerning the possible pathological status of LB1, and if it helps to recognize affinities with any hominin species and particularly if the specimen could belong to the species Homo sapiens. Medical examination of the skull based on a micro-CT examination clearly brings to light the presence of a sincipital T (a non-metrical variant of normal anatomy), a scar from an old frontal trauma without any evident functional consequence, and a severe bilateral hyperostosis frontalis interna that may have modified the anterior morphology of the endocranium of LB1. We also show that LB1 displays characteristics, related to the distribution of bone thickness and arrangements of cranial structures, that are plesiomorphic traits for hominins, at least for Homo erectus s.l. relative to Homo neanderthalensis and H. sapiens. All the microcephalic skulls analyzed here share the derived condition of anatomically modern H. sapiens. Cranial vault thickness does not help to clarify the definition of the species H. floresiensis but it also does not support an attribution of LB1 to H. sapiens. We conclude that there is no support for the attribution of LB1 to H. sapiens as there is no evidence of systemic pathology and because it does not have any of the apomorphic traits of our species. Copyright © 2016 Elsevier Ltd. All rights reserved.

Reconciling Air Force Physicians’ Peacetime and Wartime Capabilities, Demonstration of a Work Force Design Methodology.

DTIC Science & Technology

1985-08-01

training would again be required, include work on peripheral nerves, craniotomy and craniectomy (although approximately one-fifth of the -general surgeons...said never to craniotomy and craniectomy), and closed and open reductions of fractures of facial bones. Surgical subspecialty examinations can be...0 0 0 0 0 0 Free skin grfts-sites exc face 100 0 0 0 0 0 0 Free skin grafts to face 81 16 4 0 0 0 0 Craniotomy /craniectomy 7 25 11 12 11 15 19 Burr

Burr Hole Washout versus Craniotomy for Chronic Subdural Hematoma: Patient Outcome and Cost Analysis

PubMed Central

Regan, Jacqueline M.; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C.

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients’ clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings. PMID:25611468

Burr hole washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis.

PubMed

Regan, Jacqueline M; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study.

PubMed

Mahajan, Charu; Rath, Girija Prasad; Singh, Gyaninder Pal; Mishra, Nitasha; Sokhal, Suman; Bithal, Parmod Kumar

2018-01-01

The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2-0.7 μg/kg/h (bispectral index target 60-80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study

PubMed Central

Mahajan, Charu; Rath, Girija Prasad; Singh, Gyaninder Pal; Mishra, Nitasha; Sokhal, Suman; Bithal, Parmod Kumar

2018-01-01

Background: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Materials and Methods: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2–0.7 μg/kg/h (bispectral index target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). Results: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. Conclusion: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state. PMID:29628833

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study.

PubMed

Lillemäe, Kadri; Järviö, Johanna Annika; Silvasti-Lundell, Marja Kaarina; Antinheimo, Jussi Juha-Pekka; Hernesniemi, Juha Antero; Niemi, Tomi Tapio

2017-12-01

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders. Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only). The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy. POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH. Copyright © 2017 Elsevier Inc. All rights reserved.

Anesthetic management with scalp nerve block and propofol/remifentanil infusion during awake craniotomy in an adolescent patient -A case report-

PubMed Central

Sung, Bohyun; Park, Jin-Woo; Byon, Hyo-Jin; Kim, Jin-Tae; Kim, Chong Sung

2010-01-01

Despite of various neurophysiologic monitoring methods under general anesthesia, functional mapping at awake state during brain surgery is helpful for conservation of speech and motor function. But, awake craniotomy in children or adolescents is worrisome considering their emotional friabilities. We present our experience on anesthetic management for awake craniotomy in an adolescent patient. The patient was 16 years old male who would undergo awake craniotomy for removal of brain tumor. Scalp nerve block was done with local anesthetics and we infused propofol and remifentanil with target controlled infusion. The patient endured well and was cooperative before scalp suture, but when surgeon sutured scalp, he complained of pain and was suddenly agitated. We decided change to general anesthesia. Neurosurgeon did full neurologic examinations and there was no neurologic deficit except facial palsy of right side. Facial palsy had improved with time. PMID:21286435

[AWAKE CRANIOTOMY: IN SEARCH FOR OPTIMAL SEDATION].

PubMed

Kulikova, A S; Sel'kov, D A; Kobyakov, G L; Shmigel'skiy, A V; Lubnin, A Yu

2015-01-01

Awake craniotomy is a "gold standard"for intraoperative brain language mapping. One of the main anesthetic challenge of awake craniotomy is providing of optimal sedation for initial stages of intervention. The goal of this study was comparison of different technics of anesthesia for awake craniotomy. Materials and methods: 162 operations were divided in 4 groups: 76 cases with propofol sedation (2-4mg/kg/h) without airway protection; 11 cases with propofol sedation (4-5 mg/kg/h) with MV via LMA; 36 cases of xenon anesthesia; and 39 cases with dexmedetomidine sedation without airway protection. Results and discussion: brain language mapping was successful in 90% of cases. There was no difference between groups in successfulness of brain mapping. However in the first group respiratory complications were more frequent. Three other technics were more safer Xenon anesthesia was associated with ultrafast awakening for mapping (5±1 min). Dexmedetomidine sedation provided high hemodynamic and respiratory stability during the procedure.

Resting state functional connectivity magnetic resonance imaging integrated with intraoperative neuronavigation for functional mapping after aborted awake craniotomy

PubMed Central

Batra, Prag; Bandt, S. Kathleen; Leuthardt, Eric C.

2016-01-01

Background: Awake craniotomy is currently the gold standard for aggressive tumor resections in eloquent cortex. However, a significant subset of patients is unable to tolerate this procedure, particularly the very young or old or those with psychiatric comorbidities, cardiopulmonary comorbidities, or obesity, among other conditions. In these cases, typical alternative procedures include biopsy alone or subtotal resection, both of which are associated with diminished surgical outcomes. Case Description: Here, we report the successful use of a preoperatively obtained resting state functional connectivity magnetic resonance imaging (MRI) integrated with intraoperative neuronavigation software in order to perform functional cortical mapping in the setting of an aborted awake craniotomy due to loss of airway. Conclusion: Resting state functional connectivity MRI integrated with intraoperative neuronavigation software can provide an alternative option for functional cortical mapping in the setting of an aborted awake craniotomy. PMID:26958419

Use of Subdural Evacuating Port System Following Open Craniotomy with Excision of Native Dura and Membranes for Management of Chronic Subdural Hematoma.

PubMed

Cage, Tene; Bach, Ashley; McDermott, Michael W

2017-04-26

An 86-year-old woman was admitted to the intensive care unit with a chronic subdural hematoma (CSDH) and rapid onset of worsening neurological symptoms. She was taken to the operating room for a mini-craniotomy for evacuation of the CSDH including excision of the dura and CSDH membrane. Postoperatively, a subdural evacuation port system (SEPS) was integrated into the craniotomy site and left in place rather than a traditional subdural catheter drain to evacuate the subdural space postoperatively. The patient had a good recovery and improvement of symptoms after evacuation and remained clinically well after the SEPS was removed. We offer the technique of dura and CSDH membrane excision plus SEPS drain as an effective postoperative alternative to the standard craniotomy leaving the native dura intact with traditional subdural drain that overlies the cortical surface of the brain in treating patients with CSDH.

Perioperative Factors Contributing the Post-Craniotomy Pain: A Synthesis of Concepts.

PubMed

Chowdhury, Tumul; Garg, Rakesh; Sheshadri, Veena; Venkatraghavan, Lakshmi; Bergese, Sergio Daniel; Cappellani, Ronald B; Schaller, Bernhard

2017-01-01

The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients.

Perioperative Factors Contributing the Post-Craniotomy Pain: A Synthesis of Concepts

PubMed Central

Chowdhury, Tumul; Garg, Rakesh; Sheshadri, Veena; Venkatraghavan, Lakshmi; Bergese, Sergio Daniel; Cappellani, Ronald B.; Schaller, Bernhard

2017-01-01

The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients. PMID:28299313

Keyhole concept in cerebral aneurysm clipping and tumor removal by the supraciliary lateral supraorbital approach

PubMed Central

Mori, Kentaro

2014-01-01

The keyhole concept in neurosurgery is designed to minimize the craniotomy needed for the access route to deep intracranial pathologies. Such keyhole surgeries cause less trauma and can be less invasive than conventional surgical techniques. Among the various types of keyhole mini-craniotomy, supraorbital or lateral supraorbital mini-craniotomy is the standard and basic keyhole approaches. The lateral supraorbital keyhole provides adequate working space in the suprasellar to parasellar areas and planum sphenoidale area including the anterior communicating artery complex. Despite the development of neuro-endoscopic techniques and intra-operative assistant methods, the limited working angle to manipulate and observe deeply situated pathologies is a major disadvantage of the keyhole approaches. Neurosurgeons should understand that keyhole mini-craniotomy surgeries aim at “minimally invasive neurosurgery” but still carry the risks of malpractice unless we understand the advantages and disadvantages of these keyhole concepts and strategies. PMID:24891885

[The clinical and X-ray classification of osteonecrosis of the low jaw].

PubMed

Medvedev, Iu A; Basin, E M; Sokolina, I A

2013-01-01

To elaborate a clinical and X-ray classification of osteonecrosis of the low jaw in people with desomorphine or pervitin addiction. Ninety-two patients with drug addiction who had undergone orthopantomography, direct frontal X-ray of the skull, and multislice computed tomography, followed by multiplanar and three-dimensional imaging reconstruction were examined. One hundred thirty four X-ray films and 74 computed tomographic images were analyzed. The authors proposed a clinical and X-ray classification of osteonecrosis of the low jaw in people with desomorphine or pervitin addiction and elaborated recommendations for surgical interventions on the basis of the developed classification. The developed clinical and X-ray classification and recommendations for surgical interventions may be used to treat osteonecroses of various etiology.

Effect of helmet liner systems and impact directions on severity of head injuries sustained in ballistic impacts: a finite element (FE) study.

PubMed

Tse, Kwong Ming; Tan, Long Bin; Yang, Bin; Tan, Vincent Beng Chye; Lee, Heow Pueh

2017-04-01

The current study aims to investigate the effectiveness of two different designs of helmet interior cushion, (Helmet 1: strap-netting; Helmet 2: Oregon Aero foam-padding), and the effect of the impact directions on the helmeted head during ballistic impact. Series of ballistic impact simulations (frontal, lateral, rear, and top) of a full-metal-jacketed bullet were performed on a validated finite element head model equipped with the two helmets, to assess the severity of head injuries sustained in ballistic impacts using both head kinematics and biomechanical metrics. Benchmarking with experimental ventricular and intracranial pressures showed that there is good agreement between the simulations and experiments. In terms of extracranial injuries, top impact had the highest skull stress, still without fracturing the skull. In regard to intracranial injuries, both the lateral and rear impacts generally gave the highest principal strains as well as highest shear strains, which exceed the injury thresholds. Off-cushion impacts were found to be at higher risk of intracranial injuries. The study also showed that the Oregon Aero foam pads helped to reduce impact forces. It also suggested that more padding inserts of smaller size may offer better protection. This provides some insights on future's helmet design against ballistic threats.

Discriminant functions for sex estimation of modern Japanese skulls.

PubMed

Ogawa, Yoshinori; Imaizumi, Kazuhiko; Miyasaka, Sachio; Yoshino, Mineo

2013-05-01

The purpose of this study is to generate a set of discriminant functions in order to estimate the sex of modern Japanese skulls. To conduct the analysis, the anthropological measurement data of 113 individuals (73 males and 40 females) were collected from recent forensic anthropological test records at the National Research Institute of Police Science, Japan. Birth years of the individuals ranged from 1926 to 1979, and age at death was over 19 years for all individuals. A total of 10 anthropological measurements were used in the discriminant function analysis: maximum cranial length, cranial base length, maximum cranial breadth, maximum frontal breadth, basion-bregmatic height, upper facial breadth, bizygomatic breadth, bicondylar breadth, bigonial breadth, and ramal height. As a result, nine discriminant functions were established. The classification accuracy ranged from 79.0 to 89.9% when the measurements of the 113 individuals were substituted into the established functions, from 77.8 to 88.1% when a leave-one-out cross-validation procedure was applied to the data, and from 86.7 to 93.0% when the measurements of 50 new individuals (25 males and 25 females), unrelated to the establishment of the discriminant functions, were used. Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

[A murder case from 900 years ago? Analysis of extensive cranial trauma observed in a historical skeleton recovered in central Poland].

PubMed

Lorkiewicz, Wiesław; Teul, Iwona; Marchelak, Ireneusz; Tyszler, Lubomira

2011-01-01

This work presents the results of study of a human skeleton from the early Middle Ages recovered in Pecławice (province of Łódź), presenting signs of extensive cranial trauma suffered perimortem. The skeleton belonged to a 20-30 year-old male of sturdy build, with prominent bone processes, marked right-side asymmetry of the bones and joints of the upper extremities, and tallness (stature well above average for early medieval times). Except for the skull, the skeleton lacks any pathologic or traumatic lesions. The right side of the skull bears signs of three extensive injuries involving the frontal and parietal bones and the temporomandibular joint. Two of them penetrated deeply into the cranial cavity. The nature and location of the lesions suggests that the axe was used and that the victim was not confronted face-to-face. None of the lesions show any signs of healing. Fragmentation of the facial bones, which were mostly incomplete except for the well-preserved mandible, suggests additional blows to the face. These massive injuries must have been fatal due to damage to the brain and main blood vessels of the neck and thus they were recognized as the cause of death of the individual.

Advances in open microsurgery for cerebral aneurysms.

PubMed

Davies, Jason M; Lawton, Michael T

2014-02-01

Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. To review specific advances in open microsurgery for aneurysms. A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

Anesthetic approach to high-risk patients and prolonged awake craniotomy using dexmedetomidine and scalp block.

PubMed

Garavaglia, Marco M; Das, Sunit; Cusimano, Michael D; Crescini, Charmagne; Mazer, C David; Hare, Gregory M T; Rigamonti, Andrea

2014-07-01

Awake craniotomy with intraoperative speech or motor testing is relatively contraindicated in cases requiring prolonged operative times and in patients with severe medical comorbidities including anxiety, anticipated difficult airway, obesity, large tumors, and intracranial hypertension. The anesthetic management of neurosurgical patients who possess these contraindications but would be optimally treated by an awake procedure remains unclear. We describe a new anesthetic approach for awake craniotomy that did not require any airway manipulation, utilizing a bupivacaine-based scalp nerve block, and dexmedetomidine as the primary hypnotic-sedative agent. Using this technique, we provided optimal operative conditions to perform awake craniotomy facilitating safe tumor resection, while utilizing intraoperative electrocorticography for motor and speech mapping in a cohort of 10 patients at a high risk for airway compromise and complications associated with patient comorbidities. All patients underwent successful awake craniotomy, intraoperative mapping, and tumor resection with adequate sedation for up to 9 hours (median 3.5 h, range 3 to 9 h) without any loss of neurological function, airway competency, or the need to provide any active rescue airway management. We report 4 of these cases that highlight our experience: 1 case required prolonged surgery because of the complexity of tumor resection and 3 patients had important medical comorbidities and/or relative contraindication for an awake procedure. Dexmedetomidine, with concurrent scalp block, is an effective and safe anesthetic approach for awake craniotomy. Dexmedetomidine facilitates the extension procedure complexity and duration in patients who might traditionally not be considered to be candidates for this procedure.

Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors.

PubMed

Serletis, Demitre; Bernstein, Mark

2007-07-01

The authors prospectively assessed the value of awake craniotomy used nonselectively in patients undergoing resection of supratentorial tumors. The demographic features, presenting symptoms, tumor location, histological diagnosis, outcomes, and complications were documented for 610 patients who underwent awake craniotomy for supratentorial tumor resection. Intraoperative brain mapping was used in 511 cases (83.8%). Mapping identified eloquent cortex in 115 patients (22.5%) and no eloquent cortex in 396 patients (77.5%). Neurological deficits occurred in 89 patients (14.6%). In the subset of 511 patients in whom brain mapping was performed, 78 (15.3%) experienced postoperative neurological worsening. This phenomenon was more common in patients with preoperative neurological deficits or in those individuals in whom mapping successfully identified eloquent tissue. Twenty-five (4.9%) of the 511 patients suffered intraoperative seizures, and two of these individuals required intubation and induction of general anesthesia after generalized seizures occurred. Four (0.7%) of the 610 patients developed wound complications. Postoperative hematomas developed in seven patients (1.1%), four of whom urgently required a repeated craniotomy to allow evacuation of the clot. Two patients (0.3%) required readmission to the hospital soon after being discharged. There were three deaths (0.5%). Awake craniotomy is safe, practical, and effective during resection of supratentorial lesions of diverse pathological range and location. It allows for intraoperative brain mapping that helps identify and protect functional cortex. It also avoids the complications inherent in the induction of general anesthesia. Awake craniotomy provides an excellent alternative to surgery of supratentorial brain lesions in patients in whom general anesthesia has been induced.

Comparative macroanatomical study of the neurocranium in some carnivora.

PubMed

Karan, M; Timurkaan, S; Ozdemir, D; Unsaldi, E

2006-02-01

This study was carried out to investigate the specific anatomical features of the neurocranium of the skull of the dog, cat, badger, marten and otter. Twenty-five animals (five from each species) were used without sexual distinction. The neurocranium consists of os occipitale, os sphenoidale, os pterygoideum, os ethmoidale, vomer, os temporale, os parietale and os frontale. The processus paracondylaris is projected ventrally in the cat, dog, marten and badger, and caudally in the otter. Two foramina were found laterally on each side of the protuberantia occipitalis externa in the otter, and one foramen was found near the protuberantia occipitalis externa in the badger. Foramen was not seen in other species. Paired ossa parietalia joined each other at the midline, forming the sutura sagittalis in the badger, dog, otter and cat while it was separated by the linea temporalis in the marten. The os frontale was small in otters, narrow and long in martens, and quite wide in cats and dogs. The bulla tympanica was rounded in the marten, dog, cat and badger, dorsoventral compressed in otter, and it was very large in all species examined. These observations represented interspecies differences in the neurocranium of marten, otter, badger, cat and dog.

The Controlled Cortical Impact Model: Applications, Considerations for Researchers, and Future Directions

PubMed Central

Osier, Nicole D.; Dixon, C. Edward

2016-01-01

Controlled cortical impact (CCI) is a mechanical model of traumatic brain injury (TBI) that was developed nearly 30 years ago with the goal of creating a testing platform to determine the biomechanical properties of brain tissue exposed to direct mechanical deformation. Initially used to model TBIs produced by automotive crashes, the CCI model rapidly transformed into a standardized technique to study TBI mechanisms and evaluate therapies. CCI is most commonly produced using a device that rapidly accelerates a rod to impact the surgically exposed cortical dural surface. The tip of the rod can be varied in size and geometry to accommodate scalability to difference species. Typically, the rod is actuated by a pneumatic piston or electromagnetic actuator. With some limits, CCI devices can control the velocity, depth, duration, and site of impact. The CCI model produces morphologic and cerebrovascular injury responses that resemble certain aspects of human TBI. Commonly observed are graded histologic and axonal derangements, disruption of the blood–brain barrier, subdural and intra-parenchymal hematoma, edema, inflammation, and alterations in cerebral blood flow. The CCI model also produces neurobehavioral and cognitive impairments similar to those observed clinically. In contrast to other TBI models, the CCI device induces a significantly pronounced cortical contusion, but is limited in the extent to which it models the diffuse effects of TBI; a related limitation is that not all clinical TBI cases are characterized by a contusion. Another perceived limitation is that a non-clinically relevant craniotomy is performed. Biomechanically, this is irrelevant at the tissue level. However, craniotomies are not atraumatic and the effects of surgery should be controlled by including surgical sham control groups. CCI devices have also been successfully used to impact closed skulls to study mild and repetitive TBI. Future directions for CCI research surround continued refinements to the model through technical improvements in the devices (e.g., minimizing mechanical sources of variation). Like all TBI models, publications should report key injury parameters as outlined in the NIH common data elements (CDEs) for pre-clinical TBI. PMID:27582726

Post-craniotomy intracranial infection in patients with brain tumors: a retrospective analysis of 5723 consecutive patients.

PubMed

Shi, Zhong-Hua; Xu, Ming; Wang, Yong-Zhi; Luo, Xu-Ying; Chen, Guang-Qiang; Wang, Xin; Wang, Tao; Tang, Ming-Zhong; Zhou, Jian-Xin

2017-02-01

To determine the risk factors for and the incidence, outcomes, and causative pathogens of post-craniotomy intracranial infection (PCII) in patients with brain tumors. A retrospective study was performed of 5723 patients with brain tumors who were surgically treated between January 2012 and December 2013 in Beijing Tiantan Hospital. The patients' demographics, pathohistological diagnoses, surgical procedures, postoperative variables, causative pathogens, and outcomes were evaluated. The overall incidence of PCII was 6.8%, and 82.1% of all cases were diagnosed within two weeks after the craniotomy. Postoperative administration of antibiotics reduced the incidence of PCII. Independent risk factors included clean-contaminated craniotomy, prolonged operation (> 7 h), external cerebrospinal fluid (CSF) drainage/monitoring device placement, and postoperative CSF leakage. Patients ≤ 45 years old were more susceptible to infection. Compared with supratentorial tumors, tumors located in the infratentorial or intraventricular regions were more vulnerable to PCII. Gram-positive bacteria were the most common causative pathogens isolated from the CSF samples, accounting for 82.0% of the PCII cases. Risk factors for PCII can be identified early in the perioperative period. These findings raise the possibility of improving the clinical outcomes of patients with brain tumors who undergo craniotomy.

Application of COMPONT Medical Adhesive Glue for Tension-Reduced Duraplasty in Decompressive Craniotomy

PubMed Central

Zhou, Yujia; Wang, Gesheng; Liu, Jialin; Du, Yong; Wang, Lei; Wang, Xiaoyong

2016-01-01

Background The aim of this study was to evaluate the application of medical adhesive glue for tension-reduced duraplasty in decompressive craniotomy. Material/Methods A total of 56 cases were enrolled for this study from Jan 2013 to May 2015. All patients underwent decompressive craniotomy and the dura was repaired in all of them with tension-reduced duraplasty using the COMPONT medical adhesive to glue artificial dura together. The postoperative complications and the healing of dura mater were observed and recorded. Results No wound infection, epidural or subdural hematoma, cerebrospinal fluid leakage, or other complications associated with the procedure occurred, and there were no allergic reactions to the COMPONT medical adhesive glue. The second-phase surgery of cranioplasty was performed at 3 to 6 months after the decompressive craniotomy in 32 out of the 56 cases. During the cranioplasty we observed no adherence of the artificial dura mater patch to the skin flap, no residual COMPONT glue, or hydropic or contracture change of tissue at the surgical sites. Additionally, no defect or weakening of the adherence between the artificial dura mater patch and the self dura matter occurred. Conclusions COMPONT medical adhesive glue is a safe and reliable tool for tension-reduced duraplasty in decompressive craniotomy. PMID:27752035

Intraoperative seizures during craniotomy under general anesthesia.

PubMed

Howe, John; Lu, Xiaoying; Thompson, Zoe; Peterson, Gordon W; Losey, Travis E

2016-05-01

An acute symptomatic seizure is a clinical seizure occurring at the time of or in close temporal association with a brain insult. We report an acute symptomatic seizure occurring during a surgical procedure in a patient who did not have a prior history of epilepsy and who did not have a lesion associated with an increased risk of epilepsy. To characterize the incidence and clinical features of intraoperative seizures during craniotomy under general anesthesia, we reviewed cases where continuous EEG was acquired during craniotomy. Records of 400 consecutive cases with propofol as general anesthesia during craniotomy were reviewed. Demographic data, indication for surgery, clinical history, history of prior seizures, duration of surgery and duration of burst suppression were recorded. Cases where seizures were observed were analyzed in detail. Two out of 400 patients experienced intraoperative seizures, including one patient who appeared to have an acute symptomatic seizure related to the surgical procedure itself and a second patient who experienced two seizures likely related to an underlying diagnosis of epilepsy. This is the first report of an acute symptomatic seizure secondary to a neurosurgical procedure. Overall, 0.5% of patients monitored experienced seizures, indicating that intraoperative seizures are rare, and EEG monitoring during craniotomies is of low yield in detecting seizures. Copyright © 2016. Published by Elsevier Ltd.

Building an open-source robotic stereotaxic instrument.

PubMed

Coffey, Kevin R; Barker, David J; Ma, Sisi; West, Mark O

2013-10-29

This protocol includes the designs and software necessary to upgrade an existing stereotaxic instrument to a robotic (CNC) stereotaxic instrument for around $1,000 (excluding a drill), using industry standard stepper motors and CNC controlling software. Each axis has variable speed control and may be operated simultaneously or independently. The robot's flexibility and open coding system (g-code) make it capable of performing custom tasks that are not supported by commercial systems. Its applications include, but are not limited to, drilling holes, sharp edge craniotomies, skull thinning, and lowering electrodes or cannula. In order to expedite the writing of g-coding for simple surgeries, we have developed custom scripts that allow individuals to design a surgery with no knowledge of programming. However, for users to get the most out of the motorized stereotax, it would be beneficial to be knowledgeable in mathematical programming and G-Coding (simple programming for CNC machining). The recommended drill speed is greater than 40,000 rpm. The stepper motor resolution is 1.8°/Step, geared to 0.346°/Step. A standard stereotax has a resolution of 2.88 μm/step. The maximum recommended cutting speed is 500 μm/sec. The maximum recommended jogging speed is 3,500 μm/sec. The maximum recommended drill bit size is HP 2.

Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations.

PubMed

Cabrilo, Ivan; Bijlenga, Philippe; Schaller, Karl

2014-09-01

Augmented reality technology has been used for intraoperative image guidance through the overlay of virtual images, from preoperative imaging studies, onto the real-world surgical field. Although setups based on augmented reality have been used for various neurosurgical pathologies, very few cases have been reported for the surgery of arteriovenous malformations (AVM). We present our experience with AVM surgery using a system designed for image injection of virtual images into the operating microscope's eyepiece, and discuss why augmented reality may be less appealing in this form of surgery. N = 5 patients underwent AVM resection assisted by augmented reality. Virtual three-dimensional models of patients' heads, skulls, AVM nidi, and feeder and drainage vessels were selectively segmented and injected into the microscope's eyepiece for intraoperative image guidance, and their usefulness was assessed in each case. Although the setup helped in performing tailored craniotomies, in guiding dissection and in localizing drainage veins, it did not provide the surgeon with useful information concerning feeder arteries, due to the complexity of AVM angioarchitecture. The difficulty in intraoperatively conveying useful information on feeder vessels may make augmented reality a less engaging tool in this form of surgery, and might explain its underrepresentation in the literature. Integrating an AVM's hemodynamic characteristics into the augmented rendering could make it more suited to AVM surgery.

Brain surface temperature under a craniotomy

PubMed Central

Kalmbach, Abigail S.

2012-01-01

Many neuroscientists access surface brain structures via a small cranial window, opened in the bone above the brain region of interest. Unfortunately this methodology has the potential to perturb the structure and function of the underlying brain tissue. One potential perturbation is heat loss from the brain surface, which may result in local dysregulation of brain temperature. Here, we demonstrate that heat loss is a significant problem in a cranial window preparation in common use for electrical recording and imaging studies in mice. In the absence of corrective measures, the exposed surface of the neocortex was at ∼28°C, ∼10°C below core body temperature, and a standing temperature gradient existed, with tissue below the core temperature even several millimeters into the brain. Cooling affected cellular and network function in neocortex and resulted principally from increased heat loss due to convection and radiation through the skull and cranial window. We demonstrate that constant perfusion of solution, warmed to 37°C, over the brain surface readily corrects the brain temperature, resulting in a stable temperature of 36–38°C at all depths. Our results indicate that temperature dysregulation may be common in cranial window preparations that are in widespread use in neuroscience, underlining the need to take measures to maintain the brain temperature in many physiology experiments. PMID:22972953

Treatment of calvarial defects by resorbable and non-resorbable sonic activated polymer pins and mouldable titanium mesh in two dogs: a case report.

PubMed

Langer, Pierre; Black, Cameron; Egan, Padraig; Fitzpatrick, Noel

2018-06-22

To date, calvarial defects in dogs have traditionally been addressed with different types of implants including bone allograft, polymethylmethacrylate and titanium mesh secured with conventional metallic fixation methods. This report describes the use of an absorbable and non absorbable novel polymer fixation method, Bonewelding® technology, in combination with titanium mesh for the repair of calvarial defects in two dogs. The clinical outcomes and comparative complication using resorbable and non-resorbable thermoplastic pins were compared. This report of two cases documents the repair of a traumatic calvarial fracture in an adult male Greyhound and a cranioplasty following frontal bone tumor resection in an adult female Cavalier King Charles Spaniel with the use of a commercially available titanium mesh secured with an innovative thermoplastic polymer screw system (Bonewelding®). The treatment combination aimed to restore cranial structure, sinus integrity and cosmetic appearance. A mouldable titanium mesh was cut to fit the bone defect of the frontal bone and secured with either resorbable or non-resorbable polymer pins using Bonewelding® technology. Gentamycin-impregnated collagen sponge was used intraoperatively to assist with sealing of the frontal sinuses. Calvarial fracture and post-operative implant positioning were advised using computed tomography. A satisfactory restoration of skull integrity and cosmetic result was achieved, and long term clinical outcome was deemed clinically adequate with good patient quality of life. Postoperative complications including rostral mesh uplift with minor associated clinical signs were encountered when resorbable pins were used. No postoperative complications were experienced in non-resorbable pins at 7 months follow-up, by contrast mesh uplift was noted 3 weeks post-procedure in the case treated using absorbable pins. The report demonstrates the innovative use of sonic-activated polymer pins (Bonewelding® technology) alongside titanium mesh is a suitable alternative technique for skull defect repair in dogs. The use of Bonewelding® may offer advantages in reduction of surgical time. Further, ultrasonic pin application may be less invasive than alternative metallic fixation and potentially reduces bone trauma. Polymer systems may offer enhanced mesh-bone integration when compared to traditional metallic implants. The use of polymer pins demonstrates initial potential as a fixation method in cranioplasty. Initial findings in a single case comparison indicate a possible advantage in the use of non-absorbable over the absorbable systems to circumvent complications associated with variable polymer degradation, further long term studies with higher patient numbers are required before reliable conclusions can be made.

Mini-Craniotomy Under Local Anesthesia for Chronic Subdural Hematoma: An Effective Choice for Elderly Patients and for Patients in a Resource-Strained Environment.

PubMed

Mahmood, Shaikh Danish; Waqas, Muhammad; Baig, Mirza Zain; Darbar, Aneela

2017-10-01

Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA). This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged 55 years or older undergoing surgery for CSDH. Clinical characteristics, hospital stay, and recurrence rates were compared between 2 groups, local versus general anesthesia. Thirty-five patients underwent mini-craniotomy for CSDH in the study period. Sixteen patients underwent mini-craniotomy under LA versus 19 patients for GA. Median age for the LA group was 67 years compared with 70 years in the GA group. Four patients from the LA group experienced postoperative complications versus 7 from the GA group. Only one patient in the LA group required an ICU bed in the postoperative period. There was no recurrence in LA group. The overall recurrence was 2.86%. Mini-craniotomy for CSDH under LA is an equally effective procedure compared with mini-craniotomy under GA. In addition, it minimizes the risks of GA in the elderly population and obviates the need of a postoperative ICU bed. It also reduces operative time and hospital stay as compared with GA. Copyright © 2017 Elsevier Inc. All rights reserved.

Outcome of elderly patients undergoing awake-craniotomy for tumor resection.

PubMed

Grossman, Rachel; Nossek, Erez; Sitt, Razi; Hayat, Daniel; Shahar, Tal; Barzilai, Ori; Gonen, Tal; Korn, Akiva; Sela, Gal; Ram, Zvi

2013-05-01

Awake-craniotomy allows maximal tumor resection, which has been associated with extended survival. The feasibility and safety of awake-craniotomy and the effect of extent of resection on survival in the elderly population has not been established. The aim of this study was to compare surgical outcome of elderly patients undergoing awake-craniotomy to that of younger patients. Outcomes of consecutive patients younger and older than 65 years who underwent awake-craniotomy at a single institution between 2003 and 2010 were retrospectively reviewed. The groups were compared for clinical variables and surgical outcome parameters, as well as overall survival. A total of 334 young (45.4 ± 13.2 years, mean ± SD) and 90 elderly (71.7 ± 5.1 years) patients were studied. Distribution of gender, mannitol treatment, hemodynamic stability, and extent of tumor resection were similar. Significantly more younger patients had a better preoperative Karnofsky Performance Scale score (>70) than elderly patients (P = 0.0012). Older patients harbored significantly more high-grade gliomas (HGG) and brain metastases, and fewer low-grade gliomas (P < 0.0001). No significantly higher rate of mortality, or complications were observed in the elderly group. Age was associated with increased length of stay (4.9 ± 6.3 vs. 6.6 ± 7.5 days, P = 0.01). Maximal extent of tumor resection in patients with HGG was associated with prolonged survival in the elderly patients. Awake-craniotomy is a well-tolerated and safe procedure, even in elderly patients. Gross total tumor resection in elderly patients with HGG was associated with prolonged survival. The data suggest that favorable prognostic factors for patients with malignant brain tumors are also valid in elderly patients.

Classifying multiple types of hand motions using electrocorticography during intraoperative awake craniotomy and seizure monitoring processes—case studies

PubMed Central

Xie, Tao; Zhang, Dingguo; Wu, Zehan; Chen, Liang; Zhu, Xiangyang

2015-01-01

In this work, some case studies were conducted to classify several kinds of hand motions from electrocorticography (ECoG) signals during intraoperative awake craniotomy & extraoperative seizure monitoring processes. Four subjects (P1, P2 with intractable epilepsy during seizure monitoring and P3, P4 with brain tumor during awake craniotomy) participated in the experiments. Subjects performed three types of hand motions (Grasp, Thumb-finger motion and Index-finger motion) contralateral to the motor cortex covered with ECoG electrodes. Two methods were used for signal processing. Method I: autoregressive (AR) model with burg method was applied to extract features, and additional waveform length (WL) feature has been considered, finally the linear discriminative analysis (LDA) was used as the classifier. Method II: stationary subspace analysis (SSA) was applied for data preprocessing, and the common spatial pattern (CSP) was used for feature extraction before LDA decoding process. Applying method I, the three-class accuracy of P1~P4 were 90.17, 96.00, 91.77, and 92.95% respectively. For method II, the three-class accuracy of P1~P4 were 72.00, 93.17, 95.22, and 90.36% respectively. This study verified the possibility of decoding multiple hand motion types during an awake craniotomy, which is the first step toward dexterous neuroprosthetic control during surgical implantation, in order to verify the optimal placement of electrodes. The accuracy during awake craniotomy was comparable to results during seizure monitoring. This study also indicated that ECoG was a promising approach for precise identification of eloquent cortex during awake craniotomy, and might form a promising BCI system that could benefit both patients and neurosurgeons. PMID:26483627

Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas: A Cost-Minimization Study.

PubMed

Gandhoke, Gurpreet S; Pease, Matthew; Smith, Kenneth J; Sekula, Raymond F

2017-09-01

To perform a cost-minimization study comparing the supraorbital and endoscopic endonasal (EEA) approach with or without craniotomy for the resection of olfactory groove meningiomas (OGMs). We built a decision tree using probabilities of gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates with the supraorbital approach versus EEA with and without additional craniotomy. The cost (not charge or reimbursement) at each "stem" of this decision tree for both surgical options was obtained from our hospital's finance department. After a base case calculation, we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses. Probabilistic sensitivity analyses confirmed our results. The probabilities of GTR (0.8) and CSF leak (0.2) for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM. The mean tumor volume was 54.6 cm 3 (range, 17-94.2 cm 3 ). Literature-reported rates of GTR (0.6) and CSF leak (0.3) with EEA were applied to our economic analysis. Supraorbital craniotomy was the preferred strategy, with an expected value of $29,423, compared with an EEA cost of $83,838. On multiple 1-way sensitivity analyses, supraorbital craniotomy remained the preferred strategy, with a minimum cost savings of $46,000 and a maximum savings of $64,000. Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be $37,431. Compared with EEA, supraorbital craniotomy provides substantial cost savings in the treatment of OGMs. Given the potential differences in effectiveness between approaches, a cost-effectiveness analysis should be undertaken. Copyright © 2017 Elsevier Inc. All rights reserved.

Ethical challenges with awake craniotomy for tumor.

PubMed

Kirsch, Brandon; Bernstein, Mark

2012-01-01

Awake brain surgery is useful for the treatment of a number of conditions such as epilepsy and brain tumor, as well as in functional neurosurgery. Several studies have been published regarding clinical results and outcomes of patients who have undergone awake craniotomy but few have dealt with related ethical issues. The authors undertake to explore broadly the ethical issues surrounding awake brain surgery for tumor resection to encourage further consideration and discussion. Based on a review of the literature related to awake craniotomy and in part from the personal experience of the senior author, we conducted an assessment of the ethical issues associated with awake brain tumor surgery. The major ethical issues identified relate to: (1) lack of data; (2) utilization; (3) conflict of interest; (4) informed consent; (5) surgical innovation; and (6) surgical training. The authors respectfully suggest that the selection of patients for awake craniotomy needs to be monitored according to more consistent, objective standards in order to avoid conflicts of interest and potential harm to patients.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat.

PubMed

Meziane, Mohammed; Elkoundi, Abdelghafour; Ahtil, Redouane; Guazaz, Miloudi; Mustapha, Bensghir; Haimeur, Charki

2017-01-01

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient.

Use of Subdural Evacuating Port System Following Open Craniotomy with Excision of Native Dura and Membranes for Management of Chronic Subdural Hematoma

PubMed Central

Bach, Ashley; McDermott, Michael W.

2017-01-01

An 86-year-old woman was admitted to the intensive care unit with a chronic subdural hematoma (CSDH) and rapid onset of worsening neurological symptoms. She was taken to the operating room for a mini-craniotomy for evacuation of the CSDH including excision of the dura and CSDH membrane. Postoperatively, a subdural evacuation port system (SEPS) was integrated into the craniotomy site and left in place rather than a traditional subdural catheter drain to evacuate the subdural space postoperatively. The patient had a good recovery and improvement of symptoms after evacuation and remained clinically well after the SEPS was removed. We offer the technique of dura and CSDH membrane excision plus SEPS drain as an effective postoperative alternative to the standard craniotomy leaving the native dura intact with traditional subdural drain that overlies the cortical surface of the brain in treating patients with CSDH. PMID:28560123

Correction of craniosynostosis using modified spring-assisted surgery.

PubMed

Shen, Weimin; Cui, Jie; Chen, Jianbin; Zou, Jijun; Ji, Yi; Chen, Haini; Xiongzheng, Mu

2015-03-01

The use of springs in craniofacial surgery was originated at Sahlgrenska University Hospital in 1997 as a way of remodeling the cranial vault postoperatively. After a decade of development, spring technology has been improved to a greater extent. However, there still exist some problems, such as the poor consistency of steel wire stretches, the wrong position of steel wire, the problem of increasing the elasticity of springs, and so on. We have designed a spring device for external uses. This device is composed of 3 parts. The first part is the outside of the spring ring. This ring is the same as the internal spring, only a little bigger. The second part is a small U-shaped hook, which is made of titanium plates and linked to the skull portion. The U-shaped hook is approximately 1 cm long and 1 cm wide. The hang is approximately 1 cm long and 0.6 cm wide. The U-shaped level length is 1 cm, but the level width should be equal to or bigger than the thickness of the skull. The third part is a steel wire, which is placed at 1 end of hook. We first conduct a strip craniotomy, then put 2 hooks at the bone ends and, after that, fix hooks on the skull. Finally, we pull the steel wire of the hook end out of the scalp, connect it with the external spring, and draw out the external spring. We performed 24 craniofacial spring placement procedures for 12 patients with craniosynostosis. We used 6 springs for 3 patients who had anterior plagiocephaly, 12 springs for 6 patients who had scaphocephaly, and 3 springs for another patient who had metopic synostosis and holoprosencephaly. We also used 3 springs for 2 patients who had metopic synostosis. The 12 patients have not required further surgeries so far, and there were no major complications. Spring dislodgement had not caused any complication in early cases. We could easily change the position of the spring rings from outside the scalp, regularly correct the elasticity of the spring rings, and replace spring rings to increase the traction. The head shapes of the 12 children have been improved significantly to use external spring rings. This therapeutic modality in craniofacial surgery has allowed minimization of the extent of surgery without compromising clinical outcomes. The authors have shown that the use of external spring techniques is safe and, in selected situations, offer significant advantages over other methods of treatment. It makes up for a number of shortcomings of internal springs.

Comparative analysis of monotherapy versus duotherapy antiseizure drug management for postoperative seizure control in patients undergoing an awake craniotomy.

PubMed

Eseonu, Chikezie I; Eguia, Francisco; Garcia, Oscar; Kaplan, Peter W; Quiñones-Hinojosa, Alfredo

2018-06-01

OBJECTIVE Postoperative seizures are a common complication in patients undergoing an awake craniotomy, given the cortical manipulation during tumor resection and the electrical cortical stimulation for brain mapping. However, little evidence exists about the efficacy of postoperative seizure prophylaxis. This study aims to determine the most appropriate antiseizure drug (ASD) management regimen following an awake craniotomy. METHODS The authors performed a retrospective analysis of data pertaining to patients who underwent an awake craniotomy for brain tumor from 2007 to 2015 performed by a single surgeon. Patients were divided into 2 groups, those who received a single ASD (the monotherapy group) and those who received 2 types of ASDs (the duotherapy group). Patient demographics, symptoms, tumor characteristics, hospitalization details, and seizure outcome were evaluated. Multivariable logistic regression was used to evaluate numerous clinical variables associated with postoperative seizures. RESULTS A total of 81 patients underwent an awake craniotomy for tumor resection of an eloquent brain lesion. Preoperative baseline characteristics were comparable between the 2 groups. The postoperative seizure rate was 21.7% in the monotherapy group and 5.7% in the duotherapy group (p = 0.044). Seizure outcome at 6 months' follow-up was assessed with the Engel classification scale. The duotherapy group had a significantly higher proportion of seizure-free (Engel Class I) patients than the monotherapy group (90% vs 60%, p = 0.027). The length of stay was similar, 4.02 days in the monotherapy group and 4.51 days in the duotherapy group (p = 0.193). The 90-day readmission rate was higher for the monotherapy group (26.1% vs 8.5% in the duotherapy group, p = 0.044). Multivariate logistic regression showed that preoperative seizure history was a significant predictor for postoperative seizures following an awake craniotomy (OR 2.08, 95% CI 0.56-0.90, p < 0.001). CONCLUSIONS Patients with a preoperative seizure history may be at a higher risk for postoperative seizures following an awake craniotomy and may benefit from better postoperative seizure control with postoperative ASD duotherapy.

A removable silicone elastomer seal reduces granulation tissue growth and maintains the sterility of recording chambers for primate neurophysiology

PubMed Central

Spitler, Kevin M.; Gothard, Katalin M.

2008-01-01

The maintenance of the sterility of craniotomies for serial acute neurophysiological recordings is exacting and time consuming yet is vital to the health of valuable experimental animals. We have developed a method to seal the craniotomy with surgical grade silicone elastomer (Silastic®) in a hermetically sealed chamber. Under these conditions the tissues in the craniotomy and the inside surface of the chamber remain unpopulated by bacteria. The silicone elastomer sealant retarded the growth of granulation tissue on the dura and reduced the procedures required to maintain ideal conditions for neurophysiological recordings. PMID:18241928

Direct evidence from intraoperative electrocortical stimulation indicates shared and distinct speech production center between Chinese and English languages.

PubMed

Wu, Jinsong; Lu, Junfeng; Zhang, Han; Zhang, Jie; Yao, Chengjun; Zhuang, Dongxiao; Qiu, Tianming; Guo, Qihao; Hu, Xiaobing; Mao, Ying; Zhou, Liangfu

2015-12-01

Chinese processing has been suggested involving distinct brain areas from English. However, current functional localization studies on Chinese speech processing use mostly "indirect" techniques such as functional magnetic resonance imaging and electroencephalography, lacking direct evidence by means of electrocortical recording. In this study, awake craniotomies in 66 Chinese-speaking glioma patients provide a unique opportunity to directly map eloquent language areas. Intraoperative electrocortical stimulation was conducted and the positive sites for speech arrest, anomia, and alexia were identified separately. With help of stereotaxic neuronavigation system and computational modeling, all positive sites elicited by stimulation were integrated and a series of two- and three-dimension Chinese language probability maps were built. We performed statistical comparisons between the Chinese maps and previously derived English maps. While most Chinese speech arrest areas located at typical language production sites (i.e., 50% positive sites in ventral precentral gyrus, 28% in pars opercularis and pars triangularis), which also serve English production, an additional brain area, the left middle frontal gyrus (Brodmann's areas 6/9), was found to be unique in Chinese production (P < 0.05). Moreover, Chinese speakers' inferior ventral precentral gyrus (Brodmann's area 6) was used more than that in English speakers. Our finding suggests that Chinese involves more perisylvian region (extending to left middle frontal gyrus) than English. This is the first time that direct evidence supports cross-cultural neurolinguistics differences in human beings. The Chinese language atlas will also helpful in brain surgery planning for Chinese-speakers. Copyright © 2015 Wiley Periodicals, Inc.

A Political Case of Penetrating Cranial Trauma: The Injury of James Scott Brady.

PubMed

Menger, Richard; Kalakoti, Piyush; Hanif, Rimal; Ahmed, Osama; Nanda, Anil; Guthikonda, Bharat

2017-09-01

James Brady, the White House press secretary during President Ronald Reagan's first term in office, was 1 of 4 people (including the President) wounded during an attempted assassination attempt on President Reagan's life on March 30, 1981. John Hinckley, Jr. was found not guilty of this attempt by reason of insanity. The assassination attempt was a ploy by Hinckley, Jr. to impress the actress Jodie Foster. Brady was the most seriously injured of the 4 who were wounded. He suffered a gunshot wound to the left forehead that traveled through the left frontal lobe, corpus callosum, and then into the right frontal and temporal lobes. He initially required a bifrontal craniotomy for evacuation of a right frontotemporal intraparenchymal hemorrhage and debridement of tract. His postoperative course was complicated by seizures, cerebrospinal fluid leakage (necessitating multiple reparative procedures), aspiration pneumonia, and pulmonary emboli. Despite the severity of his injury and perioperative morbidities, Mr. Brady made good recovery. Although permanently left with residual weakness on the left side of his body, making a wheelchair necessary, Brady maintained cognitive and personality traits that were very close to his preinjury baseline. As a result, James Brady and his wife, Sarah, led a call to create legislative reform subsequently known as the "Brady Bill." This bill controversially made mandatory background checks for the purchase of firearms from licensed dealers. Our work aims to describe the assassination attempt, the neurosurgical injury and management of Mr. Brady's case, and the brief historical sequel that followed. Copyright © 2017 by the Congress of Neurological Surgeons.

Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study.

PubMed

Khu, Kathleen Joy; Doglietto, Francesco; Radovanovic, Ivan; Taleb, Faisal; Mendelsohn, Daniel; Zadeh, Gelareh; Bernstein, Mark

2010-05-01

Routine and nonselective use of awake and outpatient craniotomy for supratentorial tumors has been shown to be safe and effective from a medical standpoint. In this study the authors aim was to explore patients' perceptions about awake and outpatient craniotomy. Qualitative research methodology was used. Two semistructured, open-ended interviews were conducted with 27 participants, who were ambulatory adult patients who underwent craniotomy for brain tumor excision between October 2008 and April 2009. The participants were each assigned to one of the following categories: 1) awake outpatient; 2) awake inpatient; 3) outpatient under general anesthesia; and 4) inpatient under general anesthesia. Interviews were audiotaped and transcribed, and the data were subjected to thematic analysis. The following 6 overarching themes emerged from the data: 1) patients had a positive experience with awake craniotomy; 2) patient satisfaction with outpatient surgery was high; 3) patients understood the rationale behind awake surgery; 4) patients were surprised that brain surgery can be done on an outpatient basis; 5) trust in one's surgeon was important; and 6) patients were more concerned about the disease than the procedure. The results reflected positively on the patients' awake and outpatient surgery experience, but there were some areas that require improvement, specifically perioperative pain control and postoperative care. These insights on patients' perspectives can lead to better delivery of care, and ultimately, improved health outcomes.

Evaluation of Language Function under Awake Craniotomy

PubMed Central

KANNO, Aya; MIKUNI, Nobuhiro

2015-01-01

Awake craniotomy is the only established way to assess patients’ language functions intraoperatively and to contribute to their preservation, if necessary. Recent guidelines have enabled the approach to be used widely, effectively, and safely. Non-invasive brain functional imaging techniques, including functional magnetic resonance imaging and diffusion tensor imaging, have been used preoperatively to identify brain functional regions corresponding to language, and their accuracy has increased year by year. In addition, the use of neuronavigation that incorporates this preoperative information has made it possible to identify the positional relationships between the lesion and functional regions involved in language, conduct functional brain mapping in the awake state with electrical stimulation, and intraoperatively assess nerve function in real time when resecting the lesion. This article outlines the history of awake craniotomy, the current state of pre- and intraoperative evaluation of language function, and the clinical usefulness of such functional evaluation. When evaluating patients’ language functions during awake craniotomy, given the various intraoperative stresses involved, it is necessary to carefully select the tasks to be undertaken, quickly perform all examinations, and promptly evaluate the results. As language functions involve both input and output, they are strongly affected by patients’ preoperative cognitive function, degree of intraoperative wakefulness and fatigue, the ability to produce verbal articulations and utterances, as well as perform synergic movement. Therefore, it is essential to appropriately assess the reproducibility of language function evaluation using awake craniotomy techniques. PMID:25925758

Impact of preoperative functional magnetic resonance imaging during awake craniotomy procedures for intraoperative guidance and complication avoidance.

PubMed

Trinh, Victoria T; Fahim, Daniel K; Maldaun, Marcos V C; Shah, Komal; McCutcheon, Ian E; Rao, Ganesh; Lang, Frederick; Weinberg, Jeffrey; Sawaya, Raymond; Suki, Dima; Prabhu, Sujit S

2014-01-01

We wanted to study the role of functional MRI (fMRI) in preventing neurological injury in awake craniotomy patients as this has not been previously studied. To examine the role of fMRI as an intraoperative adjunct during awake craniotomy procedures. Preoperative fMRI was carried out routinely in 214 patients undergoing awake craniotomy with direct cortical stimulation (DCS). In 40% of our cases (n = 85) fMRI was utilized for the intraoperative localization of the eloquent cortex. In the other 129 cases significant noise distortion, poor task performance and nonspecific BOLD activation precluded the surgeon from using the fMRI data. Compared with DCS, fMRI had a sensitivity and specificity, respectively, of 91 and 64% in Broca's area, 93 and 18% in Wernicke's area and 100 and 100% in motor areas. A new intraoperative neurological deficit during subcortical dissection was predictive of a worsened deficit following surgery (p < 0.001). The use of fMRI for intraoperative localization was, however, not significant in preventing worsened neurological deficits, both in the immediate postoperative period (p = 1.00) and at the 3-month follow-up (p = 0.42). The routine use of fMRI was not useful in identifying language sites as performed and, more importantly, practiced tasks failed to prevent neurological deficits following awake craniotomy procedures. © 2014 S. Karger AG, Basel.

A comparison study of immune-inflammatory response in electroacupuncture and transcutaneous electrical nerve stimulation for patients undergoing supratentorial craniotomy

PubMed Central

Li, Guoyan; Li, Shuqin; Sun, Lizhi; Lin, Fangcai; Wang, Baoguo

2015-01-01

Objective: The effect of transcutaneous electrical nerve stimulation (TENS) on immuno-inflammatory response was tested and the differences between electroacupuncture (EA) and TENS in immuno-inflammatory response in patients undergoing supratentorial craniotomy were explored. Methods: 51 patients received craniotomy were randomly divided into 3 groups: control (group C, n=18), EA (group A, n=19) and TENS (group T, n=14) groups. Blood samples were collected before anesthesia (T0) and 30 min (T1), 2 h (T2) and 4 h (T3) after induction of anesthesia to measure the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-8, IL-10, IgM, IgA and IgG. Results: No significant difference existed between group A and group T during craniotomy. IgM and IgA decreased significantly in group C compared with groups A and T at T2 and T3 time points. Compared with group C, there were significant differences in TNF-α, IgM and IgA levels at T0 in groups A and T; no significant difference was found in the levels of IgG, IL-10 and IL-8. Conclusion: EA and TENS could reduce immunosuppression in patients undergoing supratentorial craniotomy and it has significance in choice of treatment in immunosuppressive therapy. PMID:25785107

A comparison study of immune-inflammatory response in electroacupuncture and transcutaneous electrical nerve stimulation for patients undergoing supratentorial craniotomy

PubMed Central

Li, Guoyan; Li, Shuqin; Sun, Lizhi; Lin, Fangcai; Wang, Baoguo

2015-01-01

Objective: The effect of transcutaneous electrical nerve stimulation (TENS) on immuno-inflammatory response was tested and the differences between electroacupuncture (EA) and TENS in immuno-inflammatory response in patients undergoing supratentorial craniotomy were explored. Methods: 51 patients received craniotomy were divided randomly into 3 groups: control (group C, n=18), EA (group A, n=19) and TENS (group T, n=14) groups. Blood samples were collected before anesthesia (T0) and 30 min (T1), 2 h (T2) and 4 h (T3) after induction of anesthesia to measure the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-8, IL-10, IgM, IgA and IgG.. Results: No significant difference existed between groups A and group T during craniotomy. IgM and IgA decreased significantly in group C compared with groups A and T at T2 and T3 time points. Compared with group C, there were significant difference in TNF-α, IgM and IgA level at T0 in groups A and T; no significant difference was found in the levels of IgG, IL-10 and IL-8. Conclusion: EA and TENS could reduce immunosuppression in patients undergoing supratentorial craniotomy and it has significance in choice of treatment in immunosuppressive therapy. PMID:25932216

Evaluation of Language Function under Awake Craniotomy.

PubMed

Kanno, Aya; Mikuni, Nobuhiro

2015-01-01

Awake craniotomy is the only established way to assess patients' language functions intraoperatively and to contribute to their preservation, if necessary. Recent guidelines have enabled the approach to be used widely, effectively, and safely. Non-invasive brain functional imaging techniques, including functional magnetic resonance imaging and diffusion tensor imaging, have been used preoperatively to identify brain functional regions corresponding to language, and their accuracy has increased year by year. In addition, the use of neuronavigation that incorporates this preoperative information has made it possible to identify the positional relationships between the lesion and functional regions involved in language, conduct functional brain mapping in the awake state with electrical stimulation, and intraoperatively assess nerve function in real time when resecting the lesion. This article outlines the history of awake craniotomy, the current state of pre- and intraoperative evaluation of language function, and the clinical usefulness of such functional evaluation. When evaluating patients' language functions during awake craniotomy, given the various intraoperative stresses involved, it is necessary to carefully select the tasks to be undertaken, quickly perform all examinations, and promptly evaluate the results. As language functions involve both input and output, they are strongly affected by patients' preoperative cognitive function, degree of intraoperative wakefulness and fatigue, the ability to produce verbal articulations and utterances, as well as perform synergic movement. Therefore, it is essential to appropriately assess the reproducibility of language function evaluation using awake craniotomy techniques.

Self-Inflicted Drywall Screws in the Sagittal Sinus.

PubMed

Guppy, Kern H; Ochi, Calvin

2018-02-01

A 30-year-old right-handed man with a history of schizophrenia presented with 2 self-inflicted drywall screws in the skull. The patient was sleepy but easily arousable; blood tests showed he had taken methamphetamines. Computed tomography and computed tomography angiography of the head showed the frontal screw abutted left of the superior sagittal sinus, and the posterior screw went through the superior sagittal sinus with no extravasation of contrast material at either site. Both screws were removed with exposure of the sagittal sinus using U-shaped craniectomies. There was no bleeding on the removal of the screws. It appears the posterior screw entered between the leaflets of the sagittal sinus dura mater. The patient had returned to work without any sequelae 1 month after injury. Copyright © 2017 Elsevier Inc. All rights reserved.

IMAGING DIAGNOSIS: COMPUTED TOMOGRAPHIC FINDINGS IN A CASE OF ADENOSQUAMOUS CARCINOMA OF THE HEAD AND NECK IN A CAT.

PubMed

Chow, Kathleen Ella; Krockenberger, Mark; Collins, David

2016-01-01

A 15-year-old female spayed domestic long-haired cat was referred for trismus, hypersalivation, and bilateral ocular discharge. On examination, the cat showed pain on palpation of the left zygomatic arch, palpable crepitus of the frontal region, and limited retropulsion of both globes. A contrast-enhanced sinonasal computed tomographic study was performed, showing facial distortion and extensive osteolysis of the skull, extending beyond the confines of the sinonasal and paranasal cavities. Additionally, soft tissue and fluid accumulation were observed in the nasal cavities and paranasal sinuses. Postmortem biopsy samples acquired from the calvarium yielded a histologic diagnosis of sinonasal adenosquamous carcinoma, a rare and particularly aggressive neoplasm previously only reported in the esophagus of one cat. © 2015 American College of Veterinary Radiology.

Comparison of the clinical efficacy of craniotomy and craniopuncture therapy for the early stage of moderate volume spontaneous intracerebral haemorrhage in basal ganglia: Using the CTA spot sign as an entry criterion.

PubMed

Ge, Chunyan; Zhao, Wangmiao; Guo, Hong; Sun, Zhaosheng; Zhang, Wanzeng; Li, Xiaowei; Yang, Xuehui; Zhang, Jinrong; Wang, Dongxin; Xiang, Yi; Mao, Jianhui; Zhang, Wenchao; Guo, Hao; Zhang, Yazhao; Chen, Jianchao

2018-06-01

Surgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml - 60 ml). From January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization. For the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups. ICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice. Copyright © 2018 Elsevier B.V. All rights reserved.

[Three cases of acute interhemispheric subdural hematoma].

PubMed

Takeda, N; Kurihara, E; Matsuoka, H; Kose, S; Tamaki, N; Matsumoto, S

1988-01-01

Traumatic acute subdural hematomas over the convexity of the cerebral hemispheres are often encountered, but acute interhemispheric subdural hematomas are rare. Fourty-eight cases of acute subdural hematomas was admitted to our hospital between 1977 and 1986, and three cases of them (6%) were located in the interhemispheric subdural space. In this paper, these three cases are reported with 20 documented cases. Case 1: an 81-year-old female was admitted to our hospital because of headache, nausea and vomiting. She hit her occiput a week ago. CT scan demonstrated contusion in the right frontal lobe and a high density in the interhemispheric space of the right frontal region. Her complaints disappeared gradually by conservative therapy and she returned to her social life. Case 2: a 50-year-old male fell downstairs and hit his vertex. As he lost consciousness, he was admitted to our hospital. He was stuporous and had left-hemiparesis. Skull X-ray film showed fracture line extending from the right temporal bone to the left parietal bone across the midline. CT scan revealed intracerebral hematoma in both frontal lobe and right parietal lobe and subarachnoid hemorrhage in the basal cistern and Sylvian fissure of the right side. And interhemispheric subdural hematoma in the right parietal region was visualized. Angiography demonstrated a lateral displacement of the right callosomarginal artery and an avascular area between the falx and the callosomarginal artery. After admission his consciousness recovered and convulsion was controlled by drug. Left-hemiparesis was improved by conservative therapy and he was discharged on foot.(ABSTRACT TRUNCATED AT 250 WORDS)

Novel Model of Frontal Impact Closed Head Injury in the Rat

PubMed Central

Kilbourne, Michael; Kuehn, Reed; Tosun, Cigdem; Caridi, John; Keledjian, Kaspar; Bochicchio, Grant; Scalea, Thomas; Gerzanich, Volodymyr

2009-01-01

Abstract Frontal impact, closed head trauma is a frequent cause of traumatic brain injury (TBI) in motor vehicle and sports accidents. Diffuse axonal injury (DAI) is common in humans and experimental animals, and results from shearing forces that develop within the anisotropic brain. Because the specific anisotropic properties of the brain are axis-dependent, the anatomical site where force is applied as well as the resultant acceleration, be it linear, rotational, or some combination, are important determinants of the resulting pattern of brain injury. Available rodent models of closed head injury do not reproduce the frontal impact commonly encountered in humans. Here we describe a new rat model of closed head injury that is a modification of the impact-acceleration model of Marmarou. In our model (the Maryland model), the impact force is applied to the anterior part of the cranium and produces TBI by causing anterior-posterior plus sagittal rotational acceleration of the brain inside the intact cranium. Skull fractures, prolonged apnea, and mortality were absent. The animals exhibited petechial hemorrhages, DAI marked by a bead-like pattern of β-amyloid precursor protein (β-APP) in damaged axons, and widespread upregulation of β-APP in neurons, with regions affected including the orbitofrontal cortex (coup), corpus callosum, caudate, putamen, thalamus, cerebellum, and brainstem. Activated caspase-3 was prominent in hippocampal neurons and Purkinje cells at the grey-white matter junction of the cerebellum. Neurobehavioral dysfunction, manifesting as reduced spontaneous exploration, lasted more than 1 week. We conclude that the Maryland model produces diffuse injuries that may be relevant to human brain injury. PMID:19929375

Local brain herniation after partial membranectomy for organized chronic subdural hematoma in an adult patient: case report and review of the literature.

PubMed

Kusano, Yoshikazu; Horiuchi, Tetsuyoshi; Seguchi, Tatsuya; Kakizawa, Yukinari; Tanaka, Yuichiro; Hongo, Kazuhiro

2010-01-01

Local brain herniation after removal of chronic subdural haematoma is extremely rare, especially in adult patients. This study reports a case of local brain herniation after partial membranectomy for organized chronic subdural haematoma. A 77-year-old man presented with dysarthria and dysphasia caused by local brain herniation of the right frontal lobe through a defect of the inner membrane. The herniated brain was detected by magnetic resonance (MR) imaging. The patient underwent a craniotomy to release the herniated and strangulated brain, which were consistent with the MR imaging findings. The patient recovered fully within 1 month after surgery. To date, five cases of brain herniation through the internal subdural membrane have been reported as complications of chronic subdural haematomas. All but one case occurred in the paediatric population. Urgent surgery should be performed, even if an adult patient suffers from local brain herniation, for preservation of brain function. This is the sixth reported case of brain herniation through a defect of the inner membrane and the second reported case in the adult population.

Brain abscess mimicking brain metastasis in breast cancer.

PubMed

Khullar, Pooja; Datta, Niloy R; Wahi, Inderjeet Kaur; Kataria, Sabeena

2016-03-01

61 year old female presented with chief complaints of headache for 30 days, fever for 10 days, altered behavior for 10 days and convulsion for 2 days. She was diagnosed and treated as a case of carcinoma of left breast 5 years ago. MRI brain showed a lobulated lesion in the left frontal lobe. She came to our hospital for whole brain radiation as a diagnosed case of carcinoma of breast with brain metastasis. Review of MRI brain scan, revealed metastasis or query infective pathology. MR spectroscopy of the lesion revealed choline: creatinine and choline: NAA (N-Acetylaspartate) ratios of ∼1.6 and 1.5 respectively with the presence of lactate within the lesion suggestive of infective pathology. She underwent left fronto temporal craniotomy and evacuation of abscess and subdural empyema. Gram stain showed gram positive cocci. After 1 month of evacuation and treatment she was fine. This case suggested a note of caution in every case of a rapidly evolving space-occupying lesion independent of the patient's previous history. Copyright © 2015 The Authors. Production and hosting by Elsevier B.V. All rights reserved.

[Comparison of extent of postoperative hydrocephalus in patients between intervertional therapy with embolism and craniotomy occlusion in Hunt-Hess III-IV level aneurysm induced subarachnoid hemorrhage and their prognosis].

PubMed

Liu, Yang; Sun, Shengkai; Chen, Xuyi; Cheng, Shixiang; Qin, Zhizhen; Liu, Xiu; Chen, Xiaochu; Ning, Lili; Wang, Zhihong

2015-02-01

To analyze and compare the difference and prognosis between vascular embolization and craniotomy occlusion in patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) with Hunt-Hess level III-IV, and acute postoperative hydrocephalus. A retrospective study was conducted on 767 patients who had undergone vascular embolization (vascular embolization group, n = 403) or craniotomy occlusion operation (craniotomy occlusion operation group, n = 364), and the patients with postoperative acute hydrocephalus were screened. The clinical data of patients of both groups was analyzed. By judging short-term prognosis in patients with hydrocephalus with Glasgow outcome scale (GOS) score estimated at discharge, the advantages and disadvantages of two surgical procedures were compared. The number of cases with postoperative hydrocephalus in vascular embolization group was 56 (13.90%), while that in craniotomy occlusion group was 33 (9.07%). The difference between the two groups of incidence of hydrocephalus was statistically significant (χ (2) = 4.350, P = 0.037). In 767 patients with aSAH, the incidence of hydrocephalus among the patients after the hematoma removal operation was significantly lower than that of patients without hematoma removal [3.07% (11/358) vs. 19.07% (78/409), χ (2) = 47.635, P = 0.000]. The incidence of hydrocephalus among the patients after ventricular drainage was significantly lower than that of patients without the drainage [2.77% (19/685) vs. 85.37% (70/82), χ (2) = 487.032, P = 0.000]. In 403 cases of vascular embolization group, the incidence of hydrocephalus in the patients after the hematoma removal operation was lower than that of patients without it [8.06% (5/62) vs. 14.96% (51/341), χ (2) = 2.082, P = 0.168]. The incidence of hydrocephalus in the patients after the ventricular drainage was lower than that of patients without drainage [2.59% (9/347) vs. 83.93% (47/56), χ (2) = 266.599, P = 0.000]. In 364 cases of craniotomy occlusion operation group, the incidence of hydrocephalus in the patients after hematoma removal operation was significantly lower than that of patients did not receive [2.03% (6/296) vs. 39.71% (27/68), χ (2) = 95.226, P = 0.000]. The incidence of hydrocephalus among the patients after the ventricular drainage was significantly lower than that of patients without drainage [2.96% (10/338) vs. 88.46% (23/26), χ (2) = 203.852, P = 0.000]. The difference in incidence of hydrocephalus between the patients who had hematoma removal surgery between vascular embolization group and craniotomy occlusion operation group was statistically significant [8.06% (5/62) vs. 2.03% (6/296), χ (2) = 4.411, P = 0.027], while no statistically difference was present in ventricular drainage patients [2.59% (9/347) vs. 2.96% (10/338), χ (2) = 0.085, P = 0.819]. There were 23 patients (41.07%) with good outcome (GOS score 4-5), while 33 (58.93%) with poor outcome (GOS score 1-3) in 56 patients undergone vascular embolization operation. Good result (GOS score 4-5) was shown in 21 (63.64%) and 12 (36.36%) with poor outcome (GOS score 1-3) among 33 patients with hydrocephalus after craniotomy occlusion operation, and the difference was statistically significant (χ (2) = 4.230, P = 0.039). Hematoma is one of the main factor contributing to the differences in the incidence of postoperative hydrocephalus of Hunt-Hess grade III-IV patients either receiving vascular embolization or craniotomy occlusion operation. Lateral ventricle drainage may not be the factor that contributes to the difference in incidence of hydrocephalus formation between the vascular embolization and craniotomy occlusion operation groups in Hunt-Hess level III-IV patients. The short term prognosis in the craniotomy occlusion operation group is superior to that of endovascular intervention embolization group.

Evaluation of anterior third of superior sagittal sinus in normal population: Identifying the subgroup with dominant drainage.

PubMed

Sahoo, Sushanta K; Ghuman, Mandeep S; Salunke, Pravin; Vyas, Sameer; Bhar, Rahat; Khandelwal, N K

2016-01-01

The ligation and transection of anterior third of superior sagittal sinus (AT-SSS) is an important step to approach anterior skull base lesions. Some clinical studies have shown frontal lobe venous infarct following such surgical procedures questioning the safety of its ligation. We have studied the variations in venous drainage patterns to AT-SSS in the normal population using postcontrast magnetic resonance venogram (MRV). A novel scoring system to recognize the subgroup with dominant venous drainage from frontal lobes has been described. In this study, 60 three-dimensional contrast-enhanced (CE) MRVs were obtained from those cases being evaluated for a headache not harboring any intracranial mass lesion. The AT-SSS with all its draining veins was studied in detail. Morphology of individual veins such as length, caliber, tributaries, and angulation with AT-SSS was studied, and a numerical value of 0 or 1 was assigned for each of the above parameters. Summing up these scores derived from the individual cortical veins quantified the drainage of AT-SSS. There are 3-4 veins on either side draining to AT-SSS. Barely, 3% of the veins had > 3 tributaries. Only 6.6% of veins had a caliber >3 mm, and 16.5% drained at acute angles to AT-SSS. About 26% of the veins did cross at least half of the lateral frontal lobe. We found in 26 individuals the AT-SSS score was 0-2, in 22 it was 3-5 and, in only in 12 (20%) the score was 6 or more (dominant drainage). There are anatomical variations in venous drainage of frontal lobes into AT-SSS. Those with dominant drainage are likely to develop venous congestion and complications if sacrificed. It is possible to identify these individuals on the basis of venous drainage pattern as shown in CE-MRV.

Severe bradycardia and hypotension after connecting negative pressure to the subgaleal drain during craniotomy closure.

PubMed

Karamchandani, K; Chouhan, R S; Bithal, P K; Dash, H H

2006-05-01

Negative pressure drainage systems are often used after craniotomy for evacuation of potential bleeding. There are several reports of haemodynamic disturbances with epidural negative pressure drainage, but such reports are very few for subgaleal drains placed over the bone flap. We report a case in which a patient developed severe cardiovascular disturbances after the vacuum drainage was connected to a subgaleal drain after craniotomy for aneurysm clipping. The patient had no significant cardiac history, had an uneventful intra-operative course and yet developed bradycardia and hypotension, which were reproducible and severe enough to require atropine administration. Anaesthetists must be aware of these effects, so that they can anticipate and treat such complications.

High-Flow Nasal Oxygen in Patient With Obstructive Sleep Apnea Undergoing Awake Craniotomy: A Case Report.

PubMed

Wong, Jaclyn W M; Kong, Amy H S; Lam, Sau Yee; Woo, Peter Y M

2017-12-15

Patients with obstructive sleep apnea are frequently considered unsuitable candidates for awake craniotomy due to anticipated problems with oxygenation, ventilation, and a potentially difficult airway. At present, only a handful of such accounts exist in the literature. Our report describes the novel use of high-flow nasal oxygen therapy for a patient with moderate obstructive sleep apnea who underwent an awake craniotomy under deep sedation. The intraoperative application of high-flow nasal oxygen therapy achieved satisfactory oxygenation, maintained the partial carbon dioxide pressure within a reasonable range even during periods of deep sedation, permitted responsive patient monitoring during mapping, and provided excellent patient and surgeon satisfaction.

Voxel-based lesion mapping of meningioma: a comprehensive lesion location mapping of 260 lesions.

PubMed

Hirayama, Ryuichi; Kinoshita, Manabu; Arita, Hideyuki; Kagawa, Naoki; Kishima, Haruhiko; Hashimoto, Naoya; Fujimoto, Yasunori; Yoshimine, Toshiki

2018-06-01

OBJECTIVE In the present study the authors aimed to determine preferred locations of meningiomas by avoiding descriptive analysis and instead using voxel-based lesion mapping and 3D image-rendering techniques. METHODS Magnetic resonance images obtained in 248 treatment-naïve meningioma patients with 260 lesions were retrospectively and consecutively collected. All images were registered to a 1-mm isotropic, high-resolution, T1-weighted brain atlas provided by the Montreal Neurological Institute (the MNI152), and a lesion frequency map was created, followed by 3D volume rendering to visualize the preferred locations of meningiomas in 3D. RESULTS The 3D lesion frequency map clearly showed that skull base structures such as parasellar, sphenoid wing, and petroclival regions were commonly affected by the tumor. The middle one-third of the superior sagittal sinus was most commonly affected in parasagittal tumors. Substantial lesion accumulation was observed around the leptomeninges covering the central sulcus and the sylvian fissure, with very few lesions observed at the frontal, parietal, and occipital convexities. CONCLUSIONS Using an objective visualization method, meningiomas were shown to be located around the middle third of the superior sagittal sinus, the perisylvian convexity, and the skull base. These observations, which are in line with previous descriptive analyses, justify further use of voxel-based lesion mapping techniques to help understand the biological nature of this disease.

Subdural Hematoma

DTIC Science & Technology

2006-07-01

characterization of more subtle associated CNS injuries. Treatment of nonacute subdural hematoma may involve craniotomy -guided hematoma evacuation...nature of this process. Note the ventricular shunt (arrow) in place for drainage of hydrocephalus, caused by significant mass effect on the...collections may require craniotomy . Because SDH may be under high intracranial pressure resultant from associated injuries, patients with the acute form

Burr-hole drainage for the treatment of acute epidural hematoma in coagulopathic patients: a report of eight cases.

PubMed

Habibi, Zohreh; Meybodi, Ali Tayebi; Haji Mirsadeghi, Seyed Mohammad; Miri, Seyed Mojtaba

2012-07-20

Craniotomy has been accepted as the treatment of choice for the management of acute epidural hematomas (AEDH). However, in practice, it seems possible to evacuate AEDH via a single burr hole instead of the traditional craniotomy in certain circumstances. Among 160 patients with AEDH meeting criteria for evacuation admitted to the emergency and accident division of our center between 2006 and 2009, we found 8 cases of hematoma appearing isodense to brain parenchyma on computed tomography (CT), who had concomitant coagulopathy. These patients were managed by burr-hole drainage for treatment of the liquefied AEDH. A closed drainage system was then kept in the epidural space for 3 days. In all 8 patients, AEDH was evacuated successfully via burr-hole placement over the site of hematoma. The level of consciousness and other symptoms improved within the first day, and no patient required an additional routine craniotomy. For patients with slowly-developing AEDH in the context of impaired coagulation, burr-hole evacuation and drainage might be a less invasive method of treatment compared to conventional craniotomy.

Intraoperative seizures and seizures outcome in patients underwent awake craniotomy.

PubMed

Yuan, Yang; Peizhi, Zhou; Xiang, Wang; Yanhui, Liu; Ruofei, Liang; Shu, Jiang; Qing, Mao

2016-11-25

Awake craniotomies (AC) could reduce neurological deficits compared with patients under general anesthesia, however, intraoperative seizure is a major reason causing awake surgery failure. The purpose of the study was to give a comprehensive overview the published articles focused on seizure incidence in awake craniotomy. Bibliographic searches of the EMBASE, MEDLINE,were performed to identify articles and conference abstracts that investigated the intraoperative seizure frequency of patients underwent AC. Twenty-five studies were included in this meta-analysis. Among the 25 included studies, one was randomized controlled trials and 5 of them were comparable studies. The pooled data suggested the general intraoperative seizure(IOS) rate for patients with AC was 8%(fixed effect model), sub-group analysis identified IOS rate for glioma patients was 8% and low grade patients was 10%. The pooled data showed early seizure rates of AC patients was 11% and late seizure rates was 35%. This systematic review and meta-analysis shows that awake craniotomy is a safe technique with relatively low intraoperative seizure occurrence. However, few RCTs were available, and the acquisition of further evidence through high-quality RCTs is highly recommended.

Awake craniotomy using electromagnetic navigation technology without rigid pin fixation.

PubMed

Morsy, Ahmed A; Ng, Wai Hoe

2015-11-01

We report our institutional experience using an electromagnetic navigation system, without rigid head fixation, for awake craniotomy patients. The StealthStation® S7 AxiEM™ navigation system (Medtronic, Inc.) was used for this technique. Detailed preoperative clinical and neuropsychological evaluations, patient education and contrast-enhanced MRI (thickness 1.5mm) were performed for each patient. The AxiEM Mobile Emitter was typically placed in a holder, which was mounted to the operating room table, and a non-invasive patient tracker was used as the patient reference device. A monitored conscious sedation technique was used in all awake craniotomy patients, and the AxiEM Navigation Pointer was used for navigation during the procedure. This offers the same accuracy as optical navigation, but without head pin fixation or interference with intraoperative neurophysiological techniques and surgical instruments. The application of the electromagnetic neuronavigation technology without rigid head fixation during an awake craniotomy is accurate, and offers superior patient comfort. It is recommended as an effective adjunctive technique for the conduct of awake surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat

PubMed Central

Meziane, Mohammed; Elkoundi, Abdelghafour; Ahtil, Redouane; Guazaz, Miloudi; Mustapha, Bensghir; Haimeur, Charki

2017-01-01

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient. PMID:28904684

Wechsler Adult Intelligence Scale-Revised Block Design broken configuration errors in nonpenetrating traumatic brain injury.

PubMed

Wilde, M C; Boake, C; Sherer, M

2000-01-01

Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.

MRimaging findings after ventricular puncture in patients with SAH.

PubMed

Tominaga, J; Shimoda, M; Oda, S; Kumasaka, A; Yamazaki, K; Tsugane, R

2001-11-01

Using magnetic resonance (MR) imaging, we studied brain injury from ventricular puncture performed during craniotomy in the acute stage of subarachnoid hemorrhage (SAH). 80 patients underwent craniotomy for aneurysm obliteration within 48 hr after SAH, ventricular puncture for drainage of cerebrospinal fluid (CSF) was performed to reduce intracranial pressure. MR imaging was performed within 3 days following surgery to measure the size of the lesion, and was repeated on postoperative days 14 and 30. Of the 80 patients with ventricular puncture preceding craniotomy, 65 (81%) showed MR evidence of brain injury from the puncture. Overall, 149 lesions were detected. According to coronal images, cortical injuries (54 cases), penetrating injury to tracts along the ventricular tube (55 cases), caudate injury (25 cases), and corpus callosum injury (15 cases). Brain injuries from ventricular puncture did not correlate significantly to patient outcome. While ventricular puncture and drainage of CSF can readily be performed to decrease brain volume at the time of craniotomy in acute-stage SAH, neurosurgeons should be aware of a surprisingly high incidence of brain injury complicating puncture.

Big Cat Coalitions: A Comparative Analysis of Regional Brain Volumes in Felidae.

PubMed

Sakai, Sharleen T; Arsznov, Bradley M; Hristova, Ani E; Yoon, Elise J; Lundrigan, Barbara L

2016-01-01

Broad-based species comparisons across mammalian orders suggest a number of factors that might influence the evolution of large brains. However, the relationship between these factors and total and regional brain size remains unclear. This study investigated the relationship between relative brain size and regional brain volumes and sociality in 13 felid species in hopes of revealing relationships that are not detected in more inclusive comparative studies. In addition, a more detailed analysis was conducted of four focal species: lions ( Panthera leo ), leopards ( Panthera pardus ), cougars ( Puma concolor ), and cheetahs ( Acinonyx jubatus ). These species differ markedly in sociality and behavioral flexibility, factors hypothesized to contribute to increased relative brain size and/or frontal cortex size. Lions are the only truly social species, living in prides. Although cheetahs are largely solitary, males often form small groups. Both leopards and cougars are solitary. Of the four species, leopards exhibit the most behavioral flexibility, readily adapting to changing circumstances. Regional brain volumes were analyzed using computed tomography. Skulls ( n = 75) were scanned to create three-dimensional virtual endocasts, and regional brain volumes were measured using either sulcal or bony landmarks obtained from the endocasts or skulls. Phylogenetic least squares regression analyses found that sociality does not correspond with larger relative brain size in these species. However, the sociality/solitary variable significantly predicted anterior cerebrum (AC) volume, a region that includes frontal cortex. This latter finding is despite the fact that the two social species in our sample, lions and cheetahs, possess the largest and smallest relative AC volumes, respectively. Additionally, an ANOVA comparing regional brain volumes in four focal species revealed that lions and leopards, while not significantly different from one another, have relatively larger AC volumes than are found in cheetahs or cougars. Further, female lions possess a significantly larger AC volume than conspecific males; female lion values were also larger than those of the other three species (regardless of sex). These results may reflect greater complexity in a female lion's social world, but additional studies are necessary. These data suggest that within family comparisons may reveal variations not easily detected by broad comparative analyses.

Big Cat Coalitions: A Comparative Analysis of Regional Brain Volumes in Felidae

PubMed Central

Sakai, Sharleen T.; Arsznov, Bradley M.; Hristova, Ani E.; Yoon, Elise J.; Lundrigan, Barbara L.

2016-01-01

Broad-based species comparisons across mammalian orders suggest a number of factors that might influence the evolution of large brains. However, the relationship between these factors and total and regional brain size remains unclear. This study investigated the relationship between relative brain size and regional brain volumes and sociality in 13 felid species in hopes of revealing relationships that are not detected in more inclusive comparative studies. In addition, a more detailed analysis was conducted of four focal species: lions (Panthera leo), leopards (Panthera pardus), cougars (Puma concolor), and cheetahs (Acinonyx jubatus). These species differ markedly in sociality and behavioral flexibility, factors hypothesized to contribute to increased relative brain size and/or frontal cortex size. Lions are the only truly social species, living in prides. Although cheetahs are largely solitary, males often form small groups. Both leopards and cougars are solitary. Of the four species, leopards exhibit the most behavioral flexibility, readily adapting to changing circumstances. Regional brain volumes were analyzed using computed tomography. Skulls (n = 75) were scanned to create three-dimensional virtual endocasts, and regional brain volumes were measured using either sulcal or bony landmarks obtained from the endocasts or skulls. Phylogenetic least squares regression analyses found that sociality does not correspond with larger relative brain size in these species. However, the sociality/solitary variable significantly predicted anterior cerebrum (AC) volume, a region that includes frontal cortex. This latter finding is despite the fact that the two social species in our sample, lions and cheetahs, possess the largest and smallest relative AC volumes, respectively. Additionally, an ANOVA comparing regional brain volumes in four focal species revealed that lions and leopards, while not significantly different from one another, have relatively larger AC volumes than are found in cheetahs or cougars. Further, female lions possess a significantly larger AC volume than conspecific males; female lion values were also larger than those of the other three species (regardless of sex). These results may reflect greater complexity in a female lion’s social world, but additional studies are necessary. These data suggest that within family comparisons may reveal variations not easily detected by broad comparative analyses. PMID:27812324

Design of a head phantom produced on a 3D rapid prototyping printer and comparison with a RANDO and 3M lucite head phantom in eye dosimetry applications

NASA Astrophysics Data System (ADS)

Homolka, Peter; Figl, Michael; Wartak, Andreas; Glanzer, Mathias; Dünkelmeyer, Martina; Hojreh, Azadeh; Hummel, Johann

2017-04-01

An anthropomorphic head phantom including eye inserts allowing placement of TLDs 3 mm below the cornea has been produced on a 3D printer using a photo-cured acrylic resin to best allow tissue equivalence. Thus Hp(3) can be determined in radiological and interventional photon radiation fields. Eye doses and doses to the forehead have been compared to an Alderson RANDO head and a 3M Lucite skull phantom in terms of surface dose per incident air kerma for frontal irradiation since the commercial phantoms do not allow placement of TLDs 3 mm below the corneal surface. A comparison of dose reduction factors (DRFs) of a common lead glasses model has also been performed. Eye dose per incident air kerma were comparable between all three phantoms (printed phantom: 1.40, standard error (SE) 0.04; RANDO: 1.36, SE 0.03; 3M: 1.37, SE 0.03). Doses to the forehead were identical to eye surface doses for the printed phantom and the RANDO head (ratio 1.00 SE 0.04, and 0.99 SE 0.03, respectively). In the 3M Lucite skull phantom dose on the forehead was 15% lower than dose to the eyes attributable to phantom properties. DRF of a sport frame style leaded glasses model with 0.75 mm lead equivalence measured were 6.8 SE 0.5, 9.3 SE 0.4 and 10.5 SE 0.5 for the RANDO head, the printed phantom, and the 3M Lucite head phantom, respectively, for frontal irradiation. A comparison of doses measured in 3 mm depth and on the surface of the eyes in the printed phantom revealed no difference larger than standard errors from TLD dosimetry. 3D printing offers an interesting opportunity for phantom design with increasing potential as printers allowing combinations of tissue substitutes will become available. Variations between phantoms may provide a useful indication of uncertainty budgets when using phantom measurements to estimate individual personnel doses.

Design of a head phantom produced on a 3D rapid prototyping printer and comparison with a RANDO and 3M lucite head phantom in eye dosimetry applications.

PubMed

Homolka, Peter; Figl, Michael; Wartak, Andreas; Glanzer, Mathias; Dünkelmeyer, Martina; Hojreh, Azadeh; Hummel, Johann

2017-04-21

An anthropomorphic head phantom including eye inserts allowing placement of TLDs 3 mm below the cornea has been produced on a 3D printer using a photo-cured acrylic resin to best allow tissue equivalence. Thus H p (3) can be determined in radiological and interventional photon radiation fields. Eye doses and doses to the forehead have been compared to an Alderson RANDO head and a 3M Lucite skull phantom in terms of surface dose per incident air kerma for frontal irradiation since the commercial phantoms do not allow placement of TLDs 3 mm below the corneal surface. A comparison of dose reduction factors (DRFs) of a common lead glasses model has also been performed. Eye dose per incident air kerma were comparable between all three phantoms (printed phantom: 1.40, standard error (SE) 0.04; RANDO: 1.36, SE 0.03; 3M: 1.37, SE 0.03). Doses to the forehead were identical to eye surface doses for the printed phantom and the RANDO head (ratio 1.00 SE 0.04, and 0.99 SE 0.03, respectively). In the 3M Lucite skull phantom dose on the forehead was 15% lower than dose to the eyes attributable to phantom properties. DRF of a sport frame style leaded glasses model with 0.75 mm lead equivalence measured were 6.8 SE 0.5, 9.3 SE 0.4 and 10.5 SE 0.5 for the RANDO head, the printed phantom, and the 3M Lucite head phantom, respectively, for frontal irradiation. A comparison of doses measured in 3 mm depth and on the surface of the eyes in the printed phantom revealed no difference larger than standard errors from TLD dosimetry. 3D printing offers an interesting opportunity for phantom design with increasing potential as printers allowing combinations of tissue substitutes will become available. Variations between phantoms may provide a useful indication of uncertainty budgets when using phantom measurements to estimate individual personnel doses.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration.

PubMed

Akcil, Eren Fatma; Dilmen, Ozlem Korkmaz; Vehid, Hayriye; Ibısoglu, Lutfiye Serap; Tunali, Yusuf

2017-03-01

The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h. This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared. The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period. The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration. Copyright © 2017 Elsevier B.V. All rights reserved.

Giant Olfactory Meningiomas

PubMed Central

d'Avella, Domenico; Salpietro, Francesco M.; Alafaci, Cetty; Tomasello, Francesco

1999-01-01

Olfactory groove meningiomas may attain surprisingly large size. The subfrontal approach is currently the route preferred by most neurosurgeons for their excision. The pterional-transsylvian route represents an alternate exposure for microsurgery of frontobasal tumors. Although this approach has been already described for olfactory meningiomas, tumors of giant size were not specifically addressed in the literature. We report the application of the pterional-transsylvian approach in six patients with giant olfactory meningiomas. This series is unique because it includes only patients with tumors exceeding 6 cm in diameter with bilateral symmetrical development. A radical removal was achieved in all patients and all of them made a full recovery. To investigate the relevance of the pterional-transsylvian approach for minimizing surgical morbidity, a magnetic resonance imaging protocol was designed to characterize even subtle postoperative frontal lobe structural changes. These changes, limited to the frontal lobe ipsilateral to exposure and localized in specific anatomical domains of the prefrontal area, included cystic degenerative alterations, parenchymal gliosis, and associated persistent white matter edema. Results from the present series strengthen the usefulness of the pterional-transsylvian approach as a safe surgical route for lesions affecting the anterior skull base, even with huge bilateral symmetrical expansion, such as giant olfactory meningiomas. ImagesFigure 1Figure 2Figure 3p26-bFigure 4p27-bFigure 5Figure 6Figure 7 PMID:17171078

Hyperostosis frontalis interna in postmenopausal women-Possible relation to osteoporosis.

PubMed

Djonic, Danijela; Bracanovic, Djurdja; Rakocevic, Zoran; Ivovic, Miomira; Nikolic, Slobodan; Zivkovic, Vladimir; Djuric, Marija

2016-01-01

To improve our understanding of hyperostosis frontalis interna (HFI), we investigated whether HFI was accompanied by changes in the postcranial skeleton. Based on head CT scan analyses, 103 postmenopausal women were divided into controls without HFI and those with HFI, in whom we measured the thickness of frontal, occipital, and parietal bones. Women in the study underwent dual energy x-ray absorptiometry to analyze the bone density of the hip and vertebral region and external geometry of the proximal femora. Additionally, all of the women completed a questionnaire about symptoms and conditions that could be related to HFI. Women with HFI had a significantly higher prevalence of headaches, neurological and psychiatric disorders, and a significantly lower prevalence of having given birth. Increased bone thickness and altered bone structure in women with HFI was localized only on the skull, particularly on the frontal bone, probably due to specific properties of its underlying dura. Bone loss in the postcranial skeleton showed the same pattern in postmenopausal women with HFI as in those without HFI. Recording of HFI in medical records can be helpful in distinguishing whether reported disorders occur as a consequence of HFI or are related to other diseases, but does not appear helpful in identifying women at risk of bone loss.

A randomised controlled trial of the effects of cryotherapy on pain, eyelid oedema and facial ecchymosis after craniotomy.

PubMed

Shin, Yong Soon; Lim, Nan Young; Yun, Sung-Cheol; Park, Kwang Ok

2009-11-01

To identify the effects of cryotherapy on patient discomfort following craniotomy. Following craniotomy, many patients suffer from unexpected discomfort, including pain, eyelid oedema and ecchymosis. Cryotherapy is regarded as a safe method for managing these postcraniotomy problems. Randomised controlled trial. A total of 97 Korean patients who underwent elective supratentorial craniotomy were randomly assigned to a cryotherapy or a control group. In the cryotherapy group, ice bags were applied to surgical wounds, and cold gel packs were applied to periorbital areas, for 20 minutes per hour, beginning three hours postoperatively and for three days thereafter. The level of patient pain was measured using the visual analogue scale while the eyelid oedema was measured using the Kara & Gokalan's scale. Ecchymosis was also classified according to its extent. The level of pain three hours after craniotomy was similar in the cryotherapy and control groups (57.9 vs. 58.7). Three days after surgery, pain had significantly decreased in the cryotherapy group (p = 0.021). After adjusting diagnosis by analysis of covariance (ANCOVA), pain score did not differ significantly between the two groups. The mean eyelid oedema scores were lower in the cryotherapy group than in the control group (0.59 vs. 2.29, p < 0.001), with ANCOVA showing that cryotherapy had a significant effect on eyelid oedema (p < 0.001). Pain (p = 0.047) and eyelid oedema (p < 0.001) in the cryotherapy group were significantly decreased over time. Ecchymosis were significantly less frequent in the cryotherapy (11/48, 22.9%) than in the control (26/49, 53.1%) group (p = 0.003). Logistic regression analysis showed that cryotherapy affected ecchymosis (p = 0.001). These results indicate that cryotherapy can control pain, eyelid oedema and facial ecchymosis after craniotomy. Cryotherapy, which is both convenient and cost-effective, can be used to prevent postoperative discomforts in a clinical setting.

Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases.

PubMed

Lüders, Jürgen C; Steinmetz, Michael P; Mayberg, Marc R

2005-01-01

Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.

An estimation of intracranial blood flow in the new-born infant.

PubMed Central

Cross, K W; Dear, P R; Hathorn, M K; Hyams, A; Kerslake, D M; Milligan, D W; Rahilly, P M; Stothers, J K

1979-01-01

1. A non-invasive method for the estimation of the intracranial blood flow of the new-born infant is described, and results obtained with it are presented. 2. The technique is a novel application of the principle of blood flow measurement by venous occlusion plethysmography. It is possible to apply a plethysmographic technique to the neonatal cranium because the presence of open sutures between the component bones permits small, but readily measurable, changes in intracranial volume to occur. 3. Skull volume changes are calculated from changes in the occipito-frontal circumference of the cranium as recorded and measured with a mercury-in-Silastic strain gauge. 4. The jugular veins in the baby's neck are occluded by finger pressure and there follows an increase in skull volume, which is rapid at first, but which decreases exponentially as venous drainage diverts to non-occluded channels such as the vertebral venous plexus. At the instant of jugular occlusion the rate of skull volume increase is representative of the rate of flow in the jugular vessels prior to occlusion, and so provides an index of the relative magnitude of the intracranial blood flow. The method thus allows changes in intracranial blood flow to be followed. When occlusion is released cranial volume decreases, initially rapidly, but slowing exponentially as resting volume is regained. 5. A theoretical model of the events occurring during the inflow and outflow phases has been developed, and a formula derived which allows an estimation to be made of the flow of blood through uncompressed channels. The measured value of jugular blood flow can then be augmented to an estimate of total intracranial flow. 6. The mean cerebral blood flow of sixteen normal babies was estimated to be 40 ml. 100 g-1.min-1 (S.D. = +/- 11.63). Images Fig. 2 Fig. 6 PMID:458665

Morphology and morphometry of the meningo-orbital foramen as a result of plastic responses to the ambient temperature and its clinical relevance.

PubMed

Tomaszewska, Agnieszka; Zelaźniewicz, Agnieszka

2014-05-01

The meningo-orbital foramen (FMO) is an osteal opening, containing vessels providing an accessory blood supply to the orbit, situated close to the superior orbital fissure. Recent studies show FMO to be ubiquitous, with localization and occurrence varying, depending on a population, what may be due to environmental conditions (ie, temperature). It is often located near the operating area in surgeries in the orbital cavity, and its accurate localization allows avoiding unexpected bleeding during intervention. Because there is a lack of clarity in the literature concerning the morphology and the morphometry of the FMO, this study aimed to clarify the issue with clinical relevance. We studied dry adult human skulls (50 men and 33 women). The morphology and minimal distances between the FMO and standard anthropologic landmarks (nasion, frontomalare orbitale, supraorbital foramen, and zygomaticomaxillary suture) were measured, using MicroScribe G2L, a three-dimensional contact scanner. We compared the result with results of previous studies on populations from various climate zones. The FMO was present in 69.88% of the skulls (56.02% of orbits): in 60.34% of the skulls, the FMO was bilateral; and in 39.66%, unilateral. We observed 74 single, 10 double, and 2 triple foramina. The FMO was present mostly on the sphenoid and the frontal bone. There was no difference in minimal distances between the FMO and the anthropologic landmarks, depending on sex, except the distance to the nasion (shorter in women). The occurrence of the FMO in the population differed from that of other populations. The results show that it is possible that the morphology and the morphometry of the FMO depend on the climate zone or ambient temperature during growth, which should be considered before performing surgery in the orbital cavity.

Skull fracture

MedlinePlus

Basilar skull fracture; Depressed skull fracture; Linear skull fracture ... Skull fractures may occur with head injuries . The skull provides good protection for the brain. However, a severe impact ...

The History of Awake Craniotomy in Hospital Universiti Sains Malaysia

PubMed Central

WAN HASSAN, Wan Mohd Nazaruddin

2013-01-01

Awake craniotomy is a brain surgery performed on awake patients and is indicated for certain intracranial pathologies. These include procedures that require an awake patient for electrocorticographic mapping or precise electrophysiological recordings, resection of lesions located close to or in the motor and speech of the brain, or minor intracranial procedures that aim to avoid general anaesthesia for faster recovery and earlier discharge. This type of brain surgery is quite new and has only recently begun to be performed in a few neurosurgical centres in Malaysia. The success of the surgery requires exceptional teamwork from the neurosurgeon, neuroanaesthesiologist, and neurologist. The aim of this article is to briefly describe the history of awake craniotomy procedures at our institution. PMID:24643321

Anisotropic composite human skull model and skull fracture validation against temporo-parietal skull fracture.

PubMed

Sahoo, Debasis; Deck, Caroline; Yoganandan, Narayan; Willinger, Rémy

2013-12-01

A composite material model for skull, taking into account damage is implemented in the Strasbourg University finite element head model (SUFEHM) in order to enhance the existing skull mechanical constitutive law. The skull behavior is validated in terms of fracture patterns and contact forces by reconstructing 15 experimental cases. The new SUFEHM skull model is capable of reproducing skull fracture precisely. The composite skull model is validated not only for maximum forces, but also for lateral impact against actual force time curves from PMHS for the first time. Skull strain energy is found to be a pertinent parameter to predict the skull fracture and based on statistical (binary logistical regression) analysis it is observed that 50% risk of skull fracture occurred at skull strain energy of 544.0mJ. © 2013 Elsevier Ltd. All rights reserved.

In vivo transcranial cavitation threshold detection during ultrasound-induced blood-brain barrier opening in mice.

PubMed

Tung, Yao-Sheng; Vlachos, Fotios; Choi, James J; Deffieux, Thomas; Selert, Kirsten; Konofagou, Elisa E

2010-10-21

The in vivo cavitation response associated with blood-brain barrier (BBB) opening as induced by transcranial focused ultrasound (FUS) in conjunction with microbubbles was studied in order to better identify the underlying mechanism in its noninvasive application. A cylindrically focused hydrophone, confocal with the FUS transducer, was used as a passive cavitation detector (PCD) to identify the threshold of inertial cavitation (IC) in the presence of Definity® microbubbles (mean diameter range: 1.1-3.3 µm, Lantheus Medical Imaging, MA, USA). A vessel phantom was first used to determine the reliability of the PCD prior to in vivo use. A cerebral blood vessel was simulated by generating a cylindrical channel of 610 µm in diameter inside a polyacrylamide gel and by saturating its volume with microbubbles. The microbubbles were sonicated through an excised mouse skull. Second, the same PCD setup was employed for in vivo noninvasive (i.e. transdermal and transcranial) cavitation detection during BBB opening. After the intravenous administration of Definity® microbubbles, pulsed FUS was applied (frequency: 1.525 or 1.5 MHz, peak-rarefactional pressure: 0.15-0.60 MPa, duty cycle: 20%, PRF: 10 Hz, duration: 1 min with a 30 s interval) to the right hippocampus of twenty-six (n = 26) mice in vivo through intact scalp and skull. T1 and T2-weighted MR images were used to verify the BBB opening. A spectrogram was generated at each pressure in order to detect the IC onset and duration. The threshold of BBB opening was found to be at a 0.30 MPa peak-rarefactional pressure in vivo. Both the phantom and in vivo studies indicated that the IC pressure threshold had a peak-rarefactional amplitude of 0.45 MPa. This indicated that BBB opening may not require IC at or near the threshold. Histological analysis showed that BBB opening could be induced without any cellular damage at 0.30 and 0.45 MPa. In conclusion, the cavitation response could be detected without craniotomy in mice and IC may not be required for BBB opening at relatively low pressures.

Neurologic Deterioration Due to Brain Sag After Bilateral Craniotomy for Subdural Hematoma Evacuation.

PubMed

Liu, James K C

2018-06-01

Intracranial hypotension from cerebrospinal fluid (CSF) hypovolemia resulting in cerebral herniation is a rare but known complication that can occur after neurosurgical procedures, usually encountered in correlation with perioperative placement of a lumbar subarachnoid drain. Decrease in CSF volume resulting in loss of buoyancy results in downward herniation of the brain without contributing mass effect, causing a phenomenon known as brain sag. Unreported previously is brain sag occurring without concomitant occult CSF leak or lumbar drainage. This case report describes a patient who underwent bilateral craniotomies for subacute on chronic subdural hematoma with successful decompression but experienced acute neurologic deterioration secondary to brain sag. Despite an initial improvement in neurologic function, he subsequently experienced progressive neurologic deterioration with evidence of cerebral herniation on neuroimaging, without evidence of continued mass effect on the brain parenchyma. After a diagnosis of brain sag was determined based on imaging criteria, the patient was placed in a flat position, which resulted in rapid improvement in his neurologic function without any further intervention. This case is unique in comparison with previous reports of intracranial hypotension after craniotomy in that the symptoms were completely reversed with positioning alone, without any evidence of active or occult CSF drainage. This report emphasizes that the diagnosis of brain sag should be taken into consideration when there is an unknown reason for neurologic decline after craniotomy, particularly bilateral craniotomies, if the imaging indicates herniation with imaging findings consistent with intracranial hypotension, without evidence of overlying mass effect. Copyright © 2018 Elsevier Inc. All rights reserved.

The effect of single low-dose dexamethasone on vomiting during awake craniotomy.

PubMed

Kamata, Kotoe; Morioka, Nobutada; Maruyama, Takashi; Komayama, Noriaki; Nitta, Masayuki; Muragaki, Yoshihiro; Kawamata, Takakazu; Ozaki, Makoto

2016-12-01

Intraoperative vomiting leads to serious respiratory complications that could influence the surgical decision-making process for awake craniotomy. However, the use of antiemetics is still limited in Japan. The aim of this study was to investigate the effect of prophylactically administered single low-dose dexamethasone on the incidence of vomiting during awake craniotomy. The frequency of hyperglycemia was also examined. We conducted a retrospective case review of awake craniotomy for glioma resection between 2012 and 2015. Of the 124 patients, 91 were included in the analysis. Dexamethasone was not used in 43 patients and the 48 remaining patients received an intravenous bolus of 4.95 mg dexamethasone at anesthetic induction. Because of stable operating conditions, no one required conscious sedation throughout functional mapping and tumor resection. Although dexamethasone pretreatment reduced the incidence of intraoperative vomiting (P = 0.027), the number of patients who complained of nausea was comparable (P = 0.969). No adverse events related to vomiting occurred intraoperatively. Baseline blood glucose concentration did not differ between each group (P = 0.143), but the samples withdrawn before emergence (P = 0.018), during the awake period (P < 0.0001) and at the end of surgery (P < 0.0001) showed significantly higher glucose levels in the dexamethasone group. Impaired wound healing was not observed in either group. A single low-dose of dexamethasone prevents intraoperative vomiting for awake craniotomy cases. However, as even a small dose of dexamethasone increases the risk for hyperglycemia, antiemetic prophylaxis with dexamethasone should be administered after careful consideration. Monitoring of perioperative blood glucose concentration is also necessary.

Epilepsy surgery in the elderly: an unusual case of a 75-year-old man with recurrent status epilepticus.

PubMed

Tellez-Zenteno, Jose F; Sadanand, Venkatraman; Riesberry, Martha; Robinson, Christopher A; Ogieglo, Lissa; Masiowski, Paul; Vrbancic, Mirna

2009-06-01

Epilepsy surgery is increasingly well-supported as an effective treatment for patients with intractable epilepsy. It is most often performed on younger patients and the safety and efficacy of epilepsy surgery in elderly patients are not frequently described. We report a case of a 75-year-old right-handed man who underwent a left fronto-temporal craniotomy for resection of a suprasellar meningioma in 2002. Immediately following hospital discharge, he began to experience complex partial seizures. He continued to have frequent seizures despite treatment with multiple combinations of antiepileptic medications. He presented with status epilepticus every two or three months, and required long periods of hospitalization on each occasion for post-ictal confusion and aphasia. Scalp EEG showed continuous spikes and polyspikes and persistent slowing in the left temporal area, as well as spikes in the left frontal area. EEG telemetry recorded multiple seizures, all with a clear focus in the left temporal area. MRI scan showed an area of encephalomalacia in the left temporal lobe, as well as post-surgical changes in the left frontal area. Neuropsychological testing showed bilateral memory impairment with no significant cognitive decline expected after unilateral temporal lobe resection. A left anteromesial temporal lobectomy was performed with intraoperative electrocorticography. Since surgery, the patient was not seizure-free (Engel class II-b), but had no further episodes of status epilepticus in one year and two months of follow-up. This is one of the oldest patients reported in the literature with epilepsy surgery and supports the possibility of epilepsy surgery in elderly patients for particular cases. In addition, few cases with such a malignant evolution of temporal lobe epilepsy have been described in this age group.

Dorello's Canal for Laymen: A Lego-Like Presentation.

PubMed

Ezer, Haim; Banerjee, Anirban Deep; Thakur, Jai Deep; Nanda, Anil

2012-06-01

Objective Dorello's canal was first described by Gruber in 1859, and later by Dorello. Vail also described the anatomy of Dorello's canal. In the preceding century, Dorello's canal was clinically important, in understanding sixth nerve palsy and nowadays it is mostly important for skull base surgery. The understanding of the three dimensional anatomy, of this canal is very difficult to understand, and there is no simple explanation for its anatomy and its relationship with adjacent structures. We present a simple, Lego-like, presentation of Dorello's canal, in a stepwise manner. Materials and Methods Dorello's canal was dissected in five formalin-fixed cadaver specimens (10 sides). The craniotomy was performed, while preserving the neural and vascular structures associated with the canal. A 3D model was created, to explain the canal's anatomy. Results Using the petrous pyramid, the sixth nerve, the cavernous sinus, the trigeminal ganglion, the petorclival ligament and the posterior clinoid, the three-dimensional structure of Dorello's canal was defined. This simple representation aids in understanding the three dimensional relationship of Dorello's canal to its neighboring structures. Conclusion Dorello's canal with its three dimensional structure and relationship to its neighboring anatomical structures could be reconstructed using a few anatomical building blocks. This method simplifies the understanding of this complex anatomical structure, and could be used for teaching purposes for aspiring neurosurgeons, and anatomy students.

Dorello's Canal for Laymen: A Lego-Like Presentation

PubMed Central

Ezer, Haim; Banerjee, Anirban Deep; Thakur, Jai Deep; Nanda, Anil

2012-01-01

Objective Dorello's canal was first described by Gruber in 1859, and later by Dorello. Vail also described the anatomy of Dorello's canal. In the preceding century, Dorello's canal was clinically important, in understanding sixth nerve palsy and nowadays it is mostly important for skull base surgery. The understanding of the three dimensional anatomy, of this canal is very difficult to understand, and there is no simple explanation for its anatomy and its relationship with adjacent structures. We present a simple, Lego-like, presentation of Dorello's canal, in a stepwise manner. Materials and Methods Dorello's canal was dissected in five formalin-fixed cadaver specimens (10 sides). The craniotomy was performed, while preserving the neural and vascular structures associated with the canal. A 3D model was created, to explain the canal's anatomy. Results Using the petrous pyramid, the sixth nerve, the cavernous sinus, the trigeminal ganglion, the petorclival ligament and the posterior clinoid, the three-dimensional structure of Dorello's canal was defined. This simple representation aids in understanding the three dimensional relationship of Dorello's canal to its neighboring structures. Conclusion Dorello's canal with its three dimensional structure and relationship to its neighboring anatomical structures could be reconstructed using a few anatomical building blocks. This method simplifies the understanding of this complex anatomical structure, and could be used for teaching purposes for aspiring neurosurgeons, and anatomy students. PMID:23730547

Conference Support - Surgery in Extreme Environments - Center for Surgical Innovation

DTIC Science & Technology

2007-01-01

flights. During this 16-day mission in April 1998, surgical procedures, including thoracotomies, laparotomies, craniotomies , laminectomies, and...fixation, craniotomy , laminectomy, and leg dissection. These experiments also permitted the evaluation of IV insertion using the autonomic protocol and...missions will be required to address: Repair of lacerations; wound cement, layered closure Incision and drainage of abscess Needle aspiration of

Awake craniotomy in a patient with ejection fraction of 10%: considerations of cerebrovascular and cardiovascular physiology.

PubMed

Meng, Lingzhong; Weston, Stephen D; Chang, Edward F; Gelb, Adrian W

2015-05-01

A 37-year-old man with nonischemic 4-chamber dilated cardiomyopathy and low-output cardiac failure (estimated ejection fraction of 10%) underwent awake craniotomy for a low-grade oligodendroglioma resection under monitored anesthesia care. The cerebrovascular and cardiovascular physiologic challenges and our management of this patient are discussed. Published by Elsevier Inc.

Delayed intracranial subdural empyema following burr hole drainage: Case series and literature review.

PubMed

Kim, You-Sub; Joo, Sung-Pil; Song, Dong-Jun; Kim, Sung-Hyun; Kim, Tae-Sun

2018-05-01

A subdural empyema (SDE) following burr hole drainage of a chronic subdural hematoma (CSDH) can be difficult to distinguish from a recurrence of the CSDH, especially when imaging data is limited to a computed tomography (CT) scan. All patients underwent burr hole drainage of the CSDH at first, and the appearance of the SDE occurred within one month. A contrast-enhanced magnetic resonance imaging (MRI) scan, with diffusion-weighted imaging (DWI), revealed both the SDE and diffuse meningitis in all patients. In Case 1, because the patient was very young, burr hole drainage of the SDE, rather than craniotomy, was performed. However, subsequent craniotomy was required due to recurrence of the SDE. In Cases 2 and 3, an initial craniotomy was performed without burr hole drainage. Symptoms improved for all patients, and each was discharged without any neurologic deficits or subsequent recurrence. Neurosurgeons should consider the possibility of infection if recurrence of CSDH occurs within 1 month following drainage of a subdural hematoma. A contrast-enhanced MRI with DWI should be performed to differentiate SDE from CSDH. In addition, surgical evacuation of the empyema via wide craniotomy is preferred to burr hole drainage.

Post-operative orofacial pain, temporomandibular dysfunction and trigeminal sensitivity after recent pterional craniotomy: preliminary study.

PubMed

Brazoloto, Thiago Medina; de Siqueira, Silvia Regina Dowgan Tesseroli; Rocha-Filho, Pedro Augusto Sampaio; Figueiredo, Eberval Gadelha; Teixeira, Manoel Jacobsen; de Siqueira, José Tadeu Tesseroli

2017-05-01

Surgical trauma at the temporalis muscle is a potential cause of post-craniotomy headache and temporomandibular disorders (TMD). The aim of this study was to evaluate the prevalence of pain, masticatory dysfunction and trigeminal somatosensory abnormalities in patients who acquired aneurysms following pterional craniotomy. Fifteen patients were evaluated before and after the surgical procedure by a trained dentist. The evaluation consisted of the (1) research diagnostic criteria for TMD, (2) a standardized orofacial pain questionnaire and (3) a systematic protocol for quantitative sensory testing (QST) for the trigeminal nerve. After pterional craniotomy, 80% of the subjects, 12 patients, developed orofacial pain triggered by mandibular function. The pain intensity was measured by using the visual analog scale (VAS), and the mean pain intensity was 3.7. The prevalence of masticatory dysfunction was 86.7%, and there was a significant reduction of the maximum mouth opening. The sensory evaluation showed tactile and thermal hypoesthesia in the area of pterional access in all patients. There was a high frequency of temporomandibular dysfunction, postoperative orofacial pain and trigeminal sensory abnormalities. These findings can help to understand several abnormalities that can contribute to postoperative headache or orofacial pain complaints after pterional surgeries.

Ammonia encephalopathy and awake craniotomy for brain language mapping: cause of failed awake craniotomy.

PubMed

Villalba Martínez, G; Fernández-Candil, J L; Vivanco-Hidalgo, R M; Pacreu Terradas, S; León Jorba, A; Arroyo Pérez, R

2015-05-01

We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Scalp marking for a craniotomy using a laser pointer during preoperative computed tomographic imaging: technical note.

PubMed

Kubo, S; Nakata, H; Sugauchi, Y; Yokota, N; Yoshimine, T

2000-05-01

The preoperative localization of superficial intracranial lesions is often necessary for accurate burr hole placement or craniotomy siting. It is not always easy, however, to localize the lesions over the scalp working only from computed tomographic images. We developed a simple method for such localization using a laser pointer during the preoperative computed tomographic examination. The angle of incidence, extending from a point on the scalp to the center of the computed tomographic image, is measured by the software included with the scanner. In the gantry, at the same angle as on the image, a laser is beamed from a handmade projector onto the patient's scalp toward the center of the gantry. The point illuminated on the patient's head corresponds to that on the image. The device and the method are described in detail herein. We applied this technique to mark the area for the craniotomy before surgery in five patients with superficial brain tumors. At the time of surgery, it was confirmed that the tumors were circumscribed precisely. The technique is easy to perform and useful in the preoperative planning for a craniotomy. In addition, the device is easily constructed and inexpensive.

Chronic subdural haematoma treated by craniotomy, durectomy, outer membranectomy and subgaleal suction drainage. Personal experience in 39 patients.

PubMed

Mohamed, E E H Hussein

2003-06-01

According to the CT and MRI appearances, 39 chronic subdural haematoma (CSDH) patients were suspected of having solid clots and/or a high likelihood of loculation. Craniotomy was planned from the start. Beside the better exposure, excision of the dura and outer membrane, assumed to be the source of haematoma fluid, this is an additional step to minimize the incidence of significant recollection. There were no additional operative or postoperative cranial and/or systemic complications when compared with other minor procedures. Two patients (5%) required once percutaneous tapping and aspiration. Accordingly, if a case is considered to be better managed with craniotomy, durectomy and outer membranectomy this is an easy and safe technique with minimal incidence of recollection, morbidity and mortality.

[Successful airway management using i-gel in 7 patients undergoing awake craniotomy].

PubMed

Matsunami, Katsuaki; Sanuki, Michiyoshi; Yasuuji, Masakazu; Nakanuno, Ryuichi; Kato, Takahiro; Kawamoto, Masashi

2014-07-01

In order to secure airway during awake craniotomy, we used i-gel to perform positive-pressure ventilation in 7 patients for their anesthetic management. During removal of a tumor around the motor speech center, anesthetic management including asleep-awake-asleep technique was applied for speech testing. The technique, insertion and re-insertion of i-gel, was needed and it was easy in all the patients. During positive-pressure ventilation, peak pressure, tidal volume both for inspiration and expiration, and endtidal-CO2 were not markedly altered. Leakage around i-gel, and its differences between inspiration and expiration were negligible, while the tidal volume was adequate. We conclude that i-gel is useful for anesthetic management for awake craniotomy procedure for both securing airway and ventilation.

Dynamic subcellular imaging of cancer cell mitosis in the brain of live mice.

PubMed

Momiyama, Masashi; Suetsugu, Atsushi; Kimura, Hiroaki; Chishima, Takashi; Bouvet, Michael; Endo, Itaru; Hoffman, Robert M

2013-04-01

The ability to visualize cancer cell mitosis and apoptosis in the brain in real time would be of great utility in testing novel therapies. In order to achieve this goal, the cancer cells were labeled with green fluorescent protein (GFP) in the nucleus and red fluorescent protein (RFP) in the cytoplasm, such that mitosis and apoptosis could be clearly imaged. A craniotomy open window was made in athymic nude mice for real-time fluorescence imaging of implanted cancer cells growing in the brain. The craniotomy window was reversibly closed with a skin flap. Mitosis of the individual cancer cells were imaged dynamically in real time through the craniotomy-open window. This model can be used to evaluate brain metastasis and brain cancer at the subcellular level.

Moral absolutism and abortion: Alan Donagan on the hysterectomy and craniotomy cases.

PubMed

Reynolds, Terrence

1985-07-01

Reynolds argues that the nonconsequentialist moral theory proposed by Alan Donagan in his book The Theory of Morality (University of Chicago Press; 1977) does not resolve the cases in which craniotomy or removal of a cancerous uterus appears necessary to save the life of a pregnant woman. Donagan's absolute prohibition against the murder of the innocent and his rejection of the principle of double effect have led him to view the fetus as a pursuer or assailant or to assert the theory of proleptic agreement--that in risk taking ventures the parties may agree that killing one person to save the lives of the others will be accepted. Reynolds holds these arguments to be inapplicable in therapeutic abortions involving craniotomy or hysterectomy and concludes that Donagan's absolutist theory must be reexamined.

[Scalp neuralgia and headache elicited by cranial superficial anatomical causes: supraorbital neuralgia, occipital neuralgia, and post-craniotomy headache].

PubMed

Shimizu, Satoru

2014-01-01

Most scalp neuralgias are supraorbital or occipital. Although they have been considered idiopathic, recent studies revealed that some were attributable to mechanical irritation with the peripheral nerve of the scalp by superficial anatomical cranial structures. Supraorbital neuralgia involves entrapment of the supraorbital nerve by the facial muscle, and occipital neuralgia involves entrapment of occipital nerves, mainly the greater occipital nerve, by the semispinalis capitis muscle. Contact between the occipital artery and the greater occipital nerve in the scalp may also be causative. Decompression surgery to address these neuralgias has been reported. As headache after craniotomy is the result of iatrogenic injury to the peripheral nerve of the scalp, post-craniotomy headache should be considered as a differential diagnosis.

Minimally invasive superficial temporal artery to middle cerebral artery bypass through a minicraniotomy: benefit of three-dimensional virtual reality planning using magnetic resonance angiography.

PubMed

Fischer, Gerrit; Stadie, Axel; Schwandt, Eike; Gawehn, Joachim; Boor, Stephan; Marx, Juergen; Oertel, Joachim

2009-05-01

The aim of the authors in this study was to introduce a minimally invasive superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery by the preselection of appropriate donor and recipient branches in a 3D virtual reality setting based on 3-T MR angiography data. An STA-MCA anastomosis was performed in each of 5 patients. Before surgery, 3-T MR imaging was performed with 3D magnetization-prepared rapid acquisition gradient echo sequences, and a high-resolution CT 3D dataset was obtained. Image fusion and the construction of a 3D virtual reality model of each patient were completed. In the 3D virtual reality setting, the skin surface, skull surface, and extra- and intracranial arteries as well as the cortical brain surface could be displayed in detail. The surgical approach was successfully visualized in virtual reality. The anatomical relationship of structures of interest could be evaluated based on different values of translucency in all cases. The closest point of the appropriate donor branch of the STA and the most suitable recipient M(3) or M(4) segment could be calculated with high accuracy preoperatively and determined as the center point of the following minicraniotomy. Localization of the craniotomy and the skin incision on top of the STA branch was calculated with the system, and these data were transferred onto the patient's skin before surgery. In all cases the preselected arteries could be found intraoperatively in exact agreement with the preoperative planning data. Successful extracranial-intracranial bypass surgery was achieved without stereotactic neuronavigation via a preselected minimally invasive approach in all cases. Subsequent enlargement of the craniotomy was not necessary. Perioperative complications were not observed. All bypasses remained patent on follow-up. With the application of a 3D virtual reality planning system, the extent of skin incision and tissue trauma as well as the size of the bone flap was minimal. The closest point of the appropriate donor branch of the STA and the most suitable recipient M(3) or M(4) segment could be preoperatively determined with high accuracy so that the STA-MCA bypass could be safely and effectively performed through an optimally located minicraniotomy with a mean diameter of 22 mm without the need for stereotactic guidance.

Nociceptive Neuropeptide Increases and Periorbital Allodynia in a Model of Traumatic Brain Injury

PubMed Central

Elliott, Melanie B.; Oshinsky, Michael L.; Amenta, Peter S.; Awe, Olatilewa O.; Jallo, Jack I.

2014-01-01

Objective This study tests the hypothesis that injury to the somatosensory cortex is associated with periorbital allodynia and increases in nociceptive neuropeptides in the brainstem in a mouse model of controlled cortical impact (CCI) injury. Methods Male C57BL/6 mice received either CCI or craniotomy-only followed by weekly periorbital von Frey (mechanical) sensory testing for up to 28 days post-injury. Mice receiving an incision only and naïve mice were included as control groups. Changes in calcitonin gene-related peptide (CGRP) and substance P (SP) within the brainstem were determined using enzyme-linked immunosorbent assay and immunohistochemistry, respectively. Activation of ionized calcium-binding adaptor molecule-1–labeled macrophages/microglia and glial fibrillary acidic protein (GFAP)-positive astrocytes were evaluated using immunohistochemistry because of their potential involvement in nociceptor sensitization. Results Incision-only control mice showed no changes from baseline periorbital von Frey mechanical thresholds. CCI significantly reduced mean periorbital von Frey thresholds (periorbital allodynia) compared with baseline and craniotomy-only at each endpoint, analysis of variance P < .0001. Craniotomy significantly reduced periorbital threshold at 14 days but not 7, 21, or 28 days compared with baseline threshold, P < .01. CCI significantly increased SP immunoreactivity in the brainstem at 7 and 14 days but not 28 days compared with craniotomy-only and controls, P < .001. CGRP levels in brainstem tissues were significantly increased in CCI groups compared with controls (incision-only and naïve mice) or craniotomy-only mice at each endpoint examined, P < .0001. There was a significant correlation between CGRP and periorbital allodynia (P < .0001, r = −0.65) but not for SP (r = 0.20). CCI significantly increased the number of macrophage/microglia in the injured cortex at each endpoint up to 28 days, although cell numbers declined over weeks post-injury, P < .001. GFAP+ immunoreactivity was significantly increased at 7 but not 14 or 28 days after CCI, P < .001. Craniotomy resulted in transient periorbital allodynia accompanied by transient increases in SP, CGRP, and GFAP immunoreactivity compared with control mice. There was no increase in the number of macrophage/microglia cells compared with controls after craniotomy. Conclusion Injury to the somatosensory cortex results in persistent periorbital allodynia and increases in brainstem nociceptive neuropeptides. Findings suggest that persistent allodynia and increased neuropeptides are maintained by mechanisms other than activation of macrophage/microglia or astrocyte in the injured somatosensory cortex. PMID:22568499

Modified irrigation hose placement in draping for craniotomy: provision of a free foot space for surgeons: technical note.

PubMed

Shimizu, S; Utsuki, S; Suzuki, S; Oka, H; Yamada, M; Fujii, K

2008-04-01

Sterility and utility are essential in surgical draping. For craniotomy, we modified the course of the irrigation hose to maintain a free foot space for the surgeon by connection with a suction bottle placed beside the patient's body through a slit made in the linen. This minor modification provides convenience to the surgeon during operations.

Organized Chronic Subdural Hematomas Treated by Large Craniotomy with Extended Membranectomy as the Initial Treatment

PubMed Central

Balevi, Mustafa

2017-01-01

Objective: The aim of this retrospective study is to evaluate the efficacy and incidence of complications of craniotomy and membranectomy in elderly patients for the treatment of organized chronic subdural hematoma (OCSH). Materials and Methods: We retrospectively reviewed a series of 28 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or computer tomography (CT) to establish the degree of organization and determine the intrahematomal architecture including inner membrane ossification. The indication to perform a primary enlarged craniotomy as initial treatment for nonliquefied OCSH with multilayer loculations was based on the hematoma MRI appearance – mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity or inner membrane calcification CT appearance - hyperdense. These cases have been treated by a large craniotomy with extended membranectomy as the initial treatment. However, the technique of a burr hole with closed system drainage for 24–72 h was chosen for cases of nonseptated and mostly liquefied Chronic Subdural Hematoma (CSDH). Results: Between 1998 and 2015, 148 consecutive patients were surgically treated for CSDH at our institution. Of these, 28 patients which have OSDH underwent a large craniotomy with extended membranectomy as the initial treatment. The average age of the patients was 69 (69.4 ± 12.1). Tension pneumocephalus (TP) has occurred in 22.8% of these patients (n = 28). Recurring subdural hemorrhage (RSH) in the operation area has occurred in 11.9% of these patients in the first 24 h. TP with RSH was seen in 4 of 8 TP patients (50%). Large epidural air was seen in one case. Postoperative seizures requiring medical therapy occurred in 25% of our patients. The average stay in the department of neurosurgery was 11 days, ranging from 7 to 28 days. Four patients died within 28 days after surgery; mortality rate was 14.28%. Conclusion: Large craniotomy and extended membrane excision for OSDH still carry a high rate of mortality and morbidity in elderly patients. TP, RSH, and postoperative seizures are frequently seen complications in elderly patients. PMID:29114271

Organized Chronic Subdural Hematomas Treated by Large Craniotomy with Extended Membranectomy as the Initial Treatment.

PubMed

Balevi, Mustafa

2017-01-01

The aim of this retrospective study is to evaluate the efficacy and incidence of complications of craniotomy and membranectomy in elderly patients for the treatment of organized chronic subdural hematoma (OCSH). We retrospectively reviewed a series of 28 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or computer tomography (CT) to establish the degree of organization and determine the intrahematomal architecture including inner membrane ossification. The indication to perform a primary enlarged craniotomy as initial treatment for nonliquefied OCSH with multilayer loculations was based on the hematoma MRI appearance - mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity or inner membrane calcification CT appearance - hyperdense. These cases have been treated by a large craniotomy with extended membranectomy as the initial treatment. However, the technique of a burr hole with closed system drainage for 24-72 h was chosen for cases of nonseptated and mostly liquefied Chronic Subdural Hematoma (CSDH). Between 1998 and 2015, 148 consecutive patients were surgically treated for CSDH at our institution. Of these, 28 patients which have OSDH underwent a large craniotomy with extended membranectomy as the initial treatment. The average age of the patients was 69 (69.4 ± 12.1). Tension pneumocephalus (TP) has occurred in 22.8% of these patients ( n = 28). Recurring subdural hemorrhage (RSH) in the operation area has occurred in 11.9% of these patients in the first 24 h. TP with RSH was seen in 4 of 8 TP patients (50%). Large epidural air was seen in one case. Postoperative seizures requiring medical therapy occurred in 25% of our patients. The average stay in the department of neurosurgery was 11 days, ranging from 7 to 28 days. Four patients died within 28 days after surgery; mortality rate was 14.28%. Large craniotomy and extended membrane excision for OSDH still carry a high rate of mortality and morbidity in elderly patients. TP, RSH, and postoperative seizures are frequently seen complications in elderly patients.

Mini-craniotomy as the primary surgical intervention for the treatment of chronic subdural hematoma--a retrospective analysis.

PubMed

Van Der Veken, Jorn; Duerinck, Johnny; Buyl, Ronald; Van Rompaey, Katrijn; Herregodts, Patrick; D'Haens, Jean

2014-05-01

The incidence of chronic subdural hematoma (CSDH) is increasing, but optimal treatment remains controversial. Recent meta-analyses suggest burr hole (BH) drainage is the best treatment because it provides optimal balance between recurrence and morbidity. Mini-craniotomy may offer supplementary technical advantages while maintaining equal or better outcomes. This study investigates the outcome of mini-craniotomy as the sole treatment in patients with CSDH. We analyzed all patients operated on for CSDH with mini-craniotomy in our neurosurgical center between 2005-2010. Baseline patient characteristics (age, sex, comorbidities, imaging characteristics, known risk factors for development of CSDH and neurological examination at presentation) and outcomes (mortality, complications, recurrence and neurological examination at discharge) were recorded. One hundred twenty-six adult patients were included, mean age was 73.9 (range 18 to 95) years old, and the sex ratio (M:F) was 2:1. Eighty-four percent of the patients showed clinical improvement at discharge, as shown by a decrease in the Markwalder score postoperatively (with 57 % Markwalder 0 and 23 % Markwalder 1). Recurrence rate was 8.7 %. Overall complication rate was 34.1 % (27.8 % medical complications and 6.3 % surgical complications). In-hospital mortality was 13.5 % (8.7 % due to pulmonary infections and 1.6 % to surgical complications). Preoperative Markwalder grade correlated significantly with complication rate, as did the presence of a neurodegenerative disease (p = 0.018). Factors significantly related to mortality in univariate analysis were arterial hypertension (p = 0.038), heart failure (p = 0.02), renal failure (p = 0.017), neurodegenerative disease (p = 0.001), cerebrovascular accident (p = 0.008) and coagulopathy (p = 0.019). Multivariate analysis was not able to confirm any significant relationship. This is the first published series of CSDH in which all consecutive patients were operated on by mini-craniotomy. The invasiveness and complication rate of mini-craniotomy are equal to those of burr hole treatment, but visualization is superior, resulting in lower recurrences. A randomized controlled trial is indicated to identify the best surgical strategy for the treatment of CSDH.

Awake craniotomy and electrophysiological mapping for eloquent area tumours.

PubMed

Chacko, Ari George; Thomas, Santhosh George; Babu, K Srinivasa; Daniel, Roy Thomas; Chacko, Geeta; Prabhu, Krishna; Cherian, Varghese; Korula, Grace

2013-03-01

An awake craniotomy facilitates radical excision of eloquent area gliomas and ensures neural integrity during the excision. The study describes our experience with 67 consecutive awake craniotomies for the excision of such tumours. Sixty-seven patients with gliomas in or adjacent to eloquent areas were included in this study. The patient was awake during the procedure and intraoperative cortical and white matter stimulation was performed to safely maximize the extent of surgical resection. Of the 883 patients who underwent craniotomies for supratentorial intraaxial tumours during the study period, 84 were chosen for an awake craniotomy. Sixty-seven with a histological diagnosis of glioma were included in this study. There were 55 men and 12 women with a median age of 34.6 years. Forty-two (62.6%) patients had positive localization on cortical stimulation. In 6 (8.9%) patients white matter stimulation was positive, five of whom had responses at the end of a radical excision. In 3 patients who developed a neurological deficit during tumour removal, white matter stimulation was negative and cessation of the surgery did not result in neurological improvement. Sixteen patients (24.6%) had intraoperative neurological deficits at the time of wound closure, 9 (13.4%) of whom had persistent mild neurological deficits at discharge, while the remaining 7 improved to normal. At a mean follow-up of 40.8 months, only 4 (5.9%) of these 9 patients had persistent neurological deficits. Awake craniotomy for excision of eloquent area gliomas enable accurate mapping of motor and language areas as well as continuous neurological monitoring during tumour removal. Furthermore, positive responses on white matter stimulation indicate close proximity of eloquent cortex and projection fibres. This should alert the surgeon to the possibility of postoperative deficits to change the surgical strategy. Thus the surgeon can resect tumour safely, with the knowledge that he has not damaged neurological function up to that point in time thus maximizing the tumour resection and minimizing neurological deficits. Copyright © 2012 Elsevier B.V. All rights reserved.

Absolute Power Spectral Density Changes in the Magnetoencephalographic Activity During the Transition from Childhood to Adulthood.

PubMed

Gómez, Carlos M; Rodríguez-Martínez, Elena I; Fernández, Alberto; Maestú, Fernando; Poza, Jesús; Gómez, Carlos

2017-01-01

The aim of this study was to define the pattern of reduction in absolute power spectral density (PSD) of magnetoencephalography (MEG) signals throughout development. Specifically, we wanted to explore whether the human skull's high permeability for electromagnetic fields would allow us to question whether the pattern of absolute PSD reduction observed in the human electroencephalogram is due to an increase in the skull's resistive properties with age. Furthermore, the topography of the MEG signals during maturation was explored, providing additional insights about the areas and brain rhythms related to late maturation in the human brain. To attain these goals, spontaneous MEG activity was recorded from 148 sensors in a sample of 59 subjects divided into three age groups: children/adolescents (7-14 years), young adults (17-20 years) and adults (21-26 years). Statistical testing was carried out by means of an analysis of variance (ANOVA), with "age group" as between-subject factor and "sensor group" as within-subject factor. Additionally, correlations of absolute PSD with age were computed to assess the influence of age on the spectral content of MEG signals. Results showed a broadband PSD decrease in frontal areas, which suggests the late maturation of this region, but also a mild increase in high frequency PSD with age in posterior areas. These findings suggest that the intensity of the neural sources during spontaneous brain activity decreases with age, which may be related to synaptic pruning.

Finite element method for analysis of stresses arising in the skull after external loading in cranio-orbital fractures.

PubMed

Wanyura, Hubert; Kowalczyk, Piotr; Bossak, Maciej; Samolczyk-Wanyura, Danuta; Stopa, Zygmunt

2012-01-01

The craniofacial skeleton remains not fully recognised as far as its mechanical resistance properties are concerned. Heretofore, the only available information on the mechanism of cranial bone fractures came from clinical observations, since the clinical evaluation in a living individual is practically impossible. It seems crucial to implement computer methods of virtual research into clinical practice. Such methods, which have long been used in the technical sciences, may either confirm or disprove previous observations. The aim of the study was to identify the areas of stress concentrations caused by external loads, which can lead to cranio-orbital fractures (COF), by the finite element method (FEM). For numerical analysis, a three-dimensional commercially available geometrical model of the skull was used which was imported into software of FEM. Computations were performed with ANSYS 12.1 Static Structural module. The loads were applied laterally to the frontal squama, the zygomatic process and partly to the upper orbital rim to locate dangerous concentration of stresses potentially resulting in COF. Changes in the area of force application revealed differences in values, quality and the extent of the stress distribution. Depending on the area of force application the following parameters would change: the value and area of stresses characteristic of COF. The distribution of stresses obtained in this study allowed definition of both the locations most vulnerable to fracture and sites from which fractures may originate or propagate.

The evolution of the complex sensory and motor systems of the human brain.

PubMed

Kaas, Jon H

2008-03-18

Inferences about how the complex sensory and motor systems of the human brain evolved are based on the results of comparative studies of brain organization across a range of mammalian species, and evidence from the endocasts of fossil skulls of key extinct species. The endocasts of the skulls of early mammals indicate that they had small brains with little neocortex. Evidence from comparative studies of cortical organization from small-brained mammals of the six major branches of mammalian evolution supports the conclusion that the small neocortex of early mammals was divided into roughly 20-25 cortical areas, including primary and secondary sensory fields. In early primates, vision was the dominant sense, and cortical areas associated with vision in temporal and occipital cortex underwent a significant expansion. Comparative studies indicate that early primates had 10 or more visual areas, and somatosensory areas with expanded representations of the forepaw. Posterior parietal cortex was also expanded, with a caudal half dominated by visual inputs, and a rostral half dominated by somatosensory inputs with outputs to an array of seven or more motor and visuomotor areas of the frontal lobe. Somatosensory areas and posterior parietal cortex became further differentiated in early anthropoid primates. As larger brains evolved in early apes and in our hominin ancestors, the number of cortical areas increased to reach an estimated 200 or so in present day humans, and hemispheric specializations emerged. The large human brain grew primarily by increasing neuron number rather than increasing average neuron size.

Biomechanical responses of a pig head under blast loading: a computational simulation.

PubMed

Zhu, Feng; Skelton, Paul; Chou, Cliff C; Mao, Haojie; Yang, King H; King, Albert I

2013-03-01

A series of computational studies were performed to investigate the biomechanical responses of the pig head under a specific shock tube environment. A finite element model of the head of a 50-kg Yorkshire pig was developed with sufficient details, based on the Lagrangian formulation, and a shock tube model was developed using the multimaterial arbitrary Lagrangian-Eulerian (MMALE) approach. These two models were integrated and a fluid/solid coupling algorithm was used to simulate the interaction of the shock wave with the pig's head. The finite element model-predicted incident and intracranial pressure traces were in reasonable agreement with those obtained experimentally. Using the verified numerical model of the shock tube and pig head, further investigations were carried out to study the spatial and temporal distributions of pressure, shear stress, and principal strain within the head. Pressure enhancement was found in the skull, which is believed to be caused by shock wave reflection at the interface of the materials with distinct wave impedances. Brain tissue has a shock attenuation effect and larger pressures were observed in the frontal and occipital regions, suggesting a greater possibility of coup and contrecoup contusion. Shear stresses in the brain and deflection in the skull remained at a low level. Higher principal strains were observed in the brain near the foramen magnum, suggesting that there is a greater chance of cellular or vascular injuries in the brainstem region. Copyright © 2012 John Wiley & Sons, Ltd.

Endoscope-Assisted Keyhole Technique for Hypertensive Cerebral Hemorrhage in Elderly Patients: A Randomized Controlled Study in 184 Patients.

PubMed

Feng, Yi; He, Jianqing; Liu, Bin; Yang, Likun; Wang, Yuhai

2016-01-01

Hypertensive cerebral hemorrhage (HCH) is a potentially life-threatening cerebrovascular disease with high mortality. In case of a massive hematoma, surgical drainage is a crucial treatment. The aim of the present study was to assess the efficacy of the endoscope-assisted keyhole technique in elderly patients with intracerebral hematoma who needed a flap craniotomy as traditional treatment. One hundred-eighty-four elderly patients with HCH, who had craniotomy indications after conservative treatment for 6-24 hours after onset, were randomly divided into two groups. In the craniotomy group, traditional hematoma drainage was performed. In the keyhole group, an endoscope-assisted keyhole technique was used. Anesthesia time, blood loss, hematoma drainage rate, and complications were compared. The clinical primary outcome was the six-month efficacy rate (defined by the activities of daily living (ADL) score). Anesthesia time was longer in the craniotomy group (3.43 ± 0.65 vs. 1.53 ± 0.52 h, P < 0.01), and blood losses were more important (256 ± 129 vs. 96 ± 39 ml P < 0.01). There was no difference in hematoma drainage rate between the two groups (77.25 ± 13.44 vs. 83.52 ± 27.51% P > 0.05). Complications, including tracheotomy (P < 0.01), pulmonary infection (P < 0.01) and hypoproteinemia (P < 0.05) were more frequent in the craniotomy group. There was no difference in the occurrence of other complications, including revision surgery digestive tract ulcer and epilepsy. Proportion of patients with good prognosis (ADL I-III) was larger in the keyhole group (P < 0.05). In elderly HCH patients with an indication for hematoma drainage, better outcomes were achieved using an endoscope-assisted keyhole technique.

The efficacy and safety of burr-hole craniotomy without continuous drainage for chronic subdural hematoma and subdural hygroma in children under 2 years of age.

PubMed

Matsuo, Kazuya; Akutsu, Nobuyuki; Otsuka, Kunitoshi; Yamamoto, Kazuki; Kawamura, Atsufumi; Nagashima, Tatsuya

2016-12-01

Various treatment modalities have been used in the management of chronic subdural hematoma and subdural hygroma (CSDH/SDHy) in children. However, few studies have examined burr-hole craniotomy without continuous drainage in such cases. Here, we retrospectively evaluated the efficacy and safety of burr-hole craniotomy without continuous drainage for CSDH/SDHy in children under 2 years old. We also aimed to determine the predictors of CSDH/SDHy recurrence. We conducted a retrospective chart review of 25 children under 2 years old who underwent burr-hole craniotomy without continuous drainage for CSDH/SDHy at a pediatric teaching hospital over a 10-year period. We analyzed the relationship between CSDH/SDHy recurrence and factors such as abusive head trauma, laterality of CSDH/SDHy, and subdural fluid collection type (hematoma or hygroma). CSDH/SDHy recurred in 5 of the 25 patients (20 %), requiring a second operation at an average of 0.92 ± 1.12 months after the initial procedure. The mean follow-up period was 25.1 ± 28.6 months. There were no complications related to either operation. None of the assessed factors were statistically associated with recurrence. Burr-hole craniotomy without continuous drainage for CSDH/SDHy appears safe in children aged under 2 years and results in a relatively low recurrence rate. No predictors of CSDH/SDHy recurrence were identified. Advantages of this method include avoiding external subdural drainage-related complications. However, burr-hole drainage may be more effective for CSDH, which our data suggests is more likely to recur than SDHy, providing the procedure is performed with specific efforts to reduce complications.

Assessment of molecular markers demonstrates concordance between samples acquired via stereotactic biopsy and open craniotomy in both anaplastic astrocytomas and glioblastomas.

PubMed

Gessler, Florian; Baumgarten, Peter; Bernstock, Joshua D; Harter, Patrick; Lescher, Stephanie; Senft, Christian; Seifert, Volker; Marquardt, Gerhard; Weise, Lutz

2017-06-01

The classification, treatment and prognosis of high-grade gliomas has been shown to correlate with the expression of molecular markers (e.g. MGMT promotor methylation and IDH1 mutations). Acquisition of tumor samples may be obtained via stereotactic biopsy or open craniotomy. Between the years 2009 and 2013, 22 patients initially diagnosed with HGGs via stereotactic biopsy, that ultimately underwent open craniotomy for resection of their tumor were prospectively included in an institutional glioma database. MGMT promotor analysis was performed using methylation-specific (MS)-PCR and IDH1R132H mutation analysis was performed using immunohistochemistry. Three patients (13.7%) exhibited IDH1R132H mutations in samples obtained via stereotactic biopsy. Tissue derived from stereotaxic biopsy was demonstrated to have MGMT promotor methylation in ten patients (45.5%), while a non-methylated MGMT promotor was demonstrated in ten patients (45.5%); inconclusive results were obtained for the remaining two patients (9%) within our cohort. The initial histologic grading, IDH1R132H mutation and MGMT promotor methylation results were confirmed using samples obtained during open craniotomy in all but one patient; here inconclusive MGMT promotor analysis was obtained in contrast to that which was obtained via stereotactic biopsy. Tumor samples acquired via stereotactic biopsy provide accurate information with regard to clinically relevant molecular markers that have been shown to impact patient care decisions. The profile of markers analyzed in our cohort was nearly concordant between those samples obtained via stereotactic biopsy or open craniotomy thereby suggesting that clinical decisions may be based on the molecular profile of the tumor samples obtained via stereotactic biopsy.

Surgery-Independent Language Function Decline in Patients Undergoing Awake Craniotomy.

PubMed

Gonen, Tal; Sela, Gal; Yanakee, Ranin; Ram, Zvi; Grossman, Rachel

2017-03-01

Despite selection process before awake-craniotomy, some patients experience an unexpected decline in language functions in the operating room (OR), compared with their baseline evaluation, which may impair their functional monitoring. To investigate this phenomenon we prospectively compared language function the day before surgery and on entrance to the OR. Data were collected prospectively from consecutive patients undergoing awake-craniotomy with intraoperative cortical mapping for resection of gliomas affecting language areas. Language functions of 79 patients were evaluated and compared 1-2 days before surgery and after entering the OR. Changes in functional linguistic performance were analyzed with respect to demographic, clinical, and pathologic characteristics. There was a significant decline in language function, beyond sedation effect, after entering the OR, (from median/interquartile range: 0.94/0.72-0.98 to median/interquartile range: 0.86/0.51-0.94; Z = -7.19, P < 0.001). Univariate analyses revealed that this decline was related to age, preoperative Karnofsky Performance Scale, tumor location, tumor pathology, and preexisting language deficits. Multivariate stepwise regression identified tumor pathology and the presence of preoperative language deficit as significant independent predictors for this functional decline. Patients undergoing awake-craniotomy may experience a substantial decline in language functioning after entering the OR. Tumor grade and the presence of preoperative language deficits were significant risk factors for this phenomenon, suggesting a possible relation between cognitive reserve, psychobehavioral coping abilities and histologic features of a tumor involving language areas. Capturing and identifying this unique population of patients who are prone to experience such language decline may improve our ability in the future to select patients eligible for awake-craniotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

[Functional mapping using subdural electrodes combined with monitoring during awake craniotomy enabled preservation of function and extensive resection of a glioma adjacent to the parietal lobe language sites: a case report].

PubMed

Takebayashi, Kento; Saito, Taiichi; Nitta, Masayuki; Tamura, Manabu; Maruyama, Takashi; Muragaki, Yoshihiro; Okada, Yoshikazu

2015-01-01

Surgical resection of gliomas located in the dominant parietal lobe is difficult because this lesion is surrounded by multiple functional areas. Although functional mapping during awake craniotomy is very useful for resection of gliomas adjacent to eloquent areas, the limited time available makes it difficult to sufficiently evaluate multiple functions, such as language, calculative ability, distinction of right and left sides, and finger recognition. Here, we report a case of anaplastic oligodendroglioma, which was successfully treated with a combination of functional mapping using subdural electrodes and monitoring under awake craniotomy for glioma. A 32-year-old man presented with generalized seizure. Magnetic resonance imaging revealed a non-enhanced tumor in the left angular and supramarginal gyri. In addition, the tumor showed high accumulation on 11C-methionine positron emission tomography(PET)(tumor/normal brain tissue ratio=3.20). Preparatory mapping using subdural electrodes showed absence of brain function on the tumor lesion. Surgical removal was performed using cortical mapping during awake craniotomy with an updated navigation system using intraoperative magnetic resonance imaging(MRI). The tumor was resected until aphasia was detected by functional monitoring, and the extent of tumor resection was 93%. The patient showed transient transcortical aphasia and Gerstmann's syndrome after surgery but eventually recovered. The pathological diagnosis was anaplastic oligodendroglioma, and the patient was administered chemo-radiotherapy. The patient has been progression free for more than 2 years. The combination of subdural electrode mapping and monitoring during awake craniotomy is useful in order to achieve preservation of function and extensive resection for gliomas in the dominant parietal lobe.

Effect of intravenous parecoxib on post-craniotomy pain.

PubMed

Williams, D L; Pemberton, E; Leslie, K

2011-09-01

Pain management in craniotomy patients is challenging, with mild-to-moderate pain intensity, moderate-to-high risk of postoperative nausea and vomiting (PONV), and potentially catastrophic consequences of analgesic-related side-effects. The aim of this study was to determine whether i.v. parecoxib administered at dural closure during craniotomy decreased total morphine consumption and morphine-related side-effects compared with placebo. One hundred adult patients presenting for supratentorial craniotomy under propofol/remifentanil anaesthesia were randomized to receive parecoxib, 40 mg i.v., or placebo in a double-blind manner. All patients received local anaesthetic scalp infiltration, regular i.v. paracetamol, nurse-administered morphine in the post-anaesthesia care unit (PACU) until verbal analogue pain scores were ≤4/10 and patient-controlled morphine thereafter. Morphine consumption, pain intensity, and analgesia-related side-effects were recorded during the first 24 h after operation. Ninety-six patients (49 control and 47 parecoxib) were included in the analyses. Fifty-nine (61%) patients received morphine in the PACU and only one patient (control) did not receive any morphine in the postoperative period. There were no significant differences between the two groups in morphine consumption [20 (range: 0-102) vs 16 (range: 1-92) mg; P=0.38], pain intensity [excellent/very good pain relief in 78% of parecoxib patients; 74% of control patients (P=0.72)] or analgesia-related side-effects (PONV in 51% of parecoxib patients; 56% of control patients; P=0.55) in the first 24 h after operation. No major morbidity was recorded. Our study demonstrated no clinical benefit to adding i.v. parecoxib to local anaesthetic scalp infiltration, i.v. paracetamol, and patient-controlled i.v. morphine after supratentorial craniotomy.

Immunohistochemical profile of neurotrophins in human cranial dura mater and meningiomas.

PubMed

Artico, Marco; Bronzetti, Elena; Pompili, Elena; Ionta, Brunella; Alicino, Valentina; D'Ambrosio, Anna; Santoro, Antonio; Pastore, Francesco S; Elenkov, Ilia; Fumagalli, Lorenzo

2009-06-01

The immunohistochemical profile of neurotrophins and their receptors in the human cranial dura mater was studied by examining certain dural zones in specimens harvested from different regions (frontal, temporal, parietal and occipital). Dural specimens were obtained during neurosurgical operations performed in ten patients for surgical treatment of intracranial lesions (meningiomas, traumas, gliomas, vascular malformations). The dural fragments were taken from the area of the craniotomy at least 8 cm from the lesion as well as from the area in which the meningioma had its dural attachment. Immunohistochemical characterization and distribution of neurotrophins, with their receptors, were analyzed. The concrete role played by these neurotrophic factors in general regulation, vascular permeability, algic responsivity and release of locally active substances in the human dura mater is still controversial. Our study revealed a general structural alteration of dural tissue due to the invasivity of meningiomatous lesions, together with an improved expression of brain derived neurotrophic factor (BDNF) in highly proliferating neoplastic cells and an evident production of nerve growth factor (NGF) in inflammatory cells, suggesting that BDNF has a role in supporting the proliferation rate of neoplastic cells, while NGF is involved in the activation of a chronic inflammatory response in neoplastic areas.

Unusual penetration of a construction nail through the orbit to the cranium: a case report.

PubMed

Erkutlu, Ibrahim; Alptekin, Mehmet; Dokur, Mehmet; Geyik, Murat; Gök, Abdulvahap

2011-01-01

Penetrating head and neck trauma with construction nails are uncommon life-threatening injuries and an important problem in developing countries. Assessment of the neurovascular and systemic physical status is a first requirement, and the decision concerning which surgical approach to perform for the removal of the nail is of critical importance. A 10-year-old girl was presented one hour after a fall injury with complaint of a swelling and foreign body lodgment on the left forehead. Neurological and systemic physical examinations were normal except for weak direct pupillary light reflex on the left side and the patient's state of uneasiness. Radiological investigations showed that the head of the nail had entered from the left infra-orbital region and become lodged through the orbital roof, below the frontal bone. Surgical extraction of the nail in the operating room was performed successfully using left pterional craniotomy and lateral orbitotomy technique, and there was no complication after surgery. Here, we report a case with a rare craniocerebral penetrating wound and type, with the head of the nail lodged in the anterior fossa through the orbital roof, which may be defined as 'reverse penetration of the nail'.

Out-of-Body Experience During Awake Craniotomy.

PubMed

Bos, Eelke M; Spoor, Jochem K H; Smits, Marion; Schouten, Joost W; Vincent, Arnaud J P E

2016-08-01

The out-of-body experience (OBE), during which a person feels as if he or she is spatially removed from the physical body, is a mystical phenomenon because of its association with near-death experiences. Literature implicates the cortex at the temporoparietal junction (TPJ) as the possible anatomic substrate for OBE. We present a patient who had an out-of-body experience during an awake craniotomy for resection of low-grade glioma. During surgery, stimulation of subcortical white matter in the left TPJ repetitively induced OBEs, in which the patient felt as if she was floating above the operating table looking down on herself. We repetitively induced OBE by subcortical stimulation near the left TPJ during awake craniotomy. Diffusion tensor imaging tractography implicated the posterior thalamic radiation as a possible substrate for autoscopic phenomena. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of Head Insulation on the Total Time Required to Rewarm Postoperative Cardiac Surgery Patients.

DTIC Science & Technology

1992-05-01

two-hour period in the recovery room. Individuals were excluded from the study if they had cardiac surgery, craniotomies , surgeries precluding the use...years). Patients were excluded if they had: craniotomies , cardiac surgery, coagulation defects, 34 preoperative hyperthermia, or previous tympanoplasty...intraoperatively. 3. Postoperative mediastinal/chest tube drainage > 100 ml/hour for four hours. 4. Postoperative cardiac arrest during data collection period

Bioacoustic Signal Classification in Cat Auditory Cortex

DTIC Science & Technology

1991-06-14

Studies Preparations for the setup to record from awake animals in a behavioral setting were initiated with the help of Dr. William Jenkins, our...temporal muscle over the right hemisphere was then retracted and the lateral cortex exposed by a craniotomy . The dura overlaying the middle ectosylvian...sites. For recording topographically identified single neurons, a wire mesh was placed over the craniotomy and the space between the grid and cortex was

Pneumocranium secondary to halo vest pin penetration through an enlarged frontal sinus.

PubMed

Cheong, Min Lee; Chan, Chris Yin Wei; Saw, Lim Beng; Kwan, Mun Keong

2009-07-01

We present a case report of a patient with pneumocranium secondary to halo vest pin penetration and a review of literature. The objectives of this study are to report a rare complication of halo vest pin insertion and to discuss methods of prevention of this complication. Halo vest orthosis is a commonly used and well-tolerated upper cervical spinal stabilizing device. Reports of complications related to pin penetration is rare and from our review, there has been no reports of pneumocranium occurring from insertion of pins following standard anatomical landmarks. A 57-year-old male sustained a type 1 traumatic spondylolisthesis of C2/C3 following a motor vehicle accident. During application of the halo vest, penetration of the left anterior pin through the abnormally enlarged frontal sinus occurred. The patient developed headache, vomiting and CSF rhinorrhoea over his left nostril. He was treated with intravenous Ceftriaxone for 1 week. This resulted in resolution of his symptoms as well as the pneumocranium. In conclusion, complications of halo vest pin penetration are rare and need immediate recognition. Despite the use of anatomical landmarks, pin penetration is still possible due to aberrant anatomy. All patients should have a skull X-ray with a radio-opaque marker done prior to placement of the halo vest pins and halo vest pins have to be inserted by experienced personnel to enable early detection of pin penetration.

Radiotelemetry recording of electroencephalogram in piglets during rest.

PubMed

Saito, Toshiyuki; Watanabe, Yasuko; Nemoto, Tetsu; Kasuya, Etsuko; Sakumoto, Ryosuke

2005-04-13

A wireless recording system was developed to study the electroencephalogram (EEG) in unrestrained, male Landrace piglets. Under general anesthesia, ball-tipped silver/silver chloride electrodes for EEG recording were implanted onto the dura matter of the parietal and frontal cortex of the piglets. A pair of miniature preamplifiers and transmitters was then mounted on the surface of the skull. To examine whether other bioelectrical activities interfere with the EEG measurements, an electrocardiogram (ECG) or electromyogram (EMG) of the neck was simultaneously recorded with the EEG. Next, wire electrodes for recording movement of the eyelid were implanted with EEG electrodes, and EEG and eyelid movements were simultaneously measured. Power spectral analysis using a Fast Fourier Transformation (FFT) algorithm indicates that EEG was successfully recorded in unrestrained piglets, at rest, during the daytime in the absence of interference from ECG, EMG or eyelid movements. These data indicate the feasibility of using our radiotelemetry system for measurement of EEG under these conditions.

Analysis of the influence of the macro- and microstructure of dental zirconium implants on osseointegration: a minipig study.

PubMed

Mueller, Cornelia Katharina; Solcher, Philipp; Peisker, Andrè; Mtsariashvilli, Maia; Schlegel, Karl Andreas; Hildebrand, Gerhard; Rost, Juergen; Liefeith, Klaus; Chen, Jiang; Schultze-Mosgau, Stefan

2013-07-01

It was the aim of this study to analyze the influence of implant design and surface topography on the osseointegration of dental zirconium implants. Six different implant designs were tested in the study. Nine or 10 test implants were inserted in the frontal skull in each of 10 miniature pigs. Biopsies were harvested after 2 and 4 months and subjected to microradiography. No significant differences between titanium and zirconium were found regarding the microradiographically detected bone-implant contact (BIC). Cylindric zirconium implants showed a higher BIC at the 2-month follow-up than conic zirconium implants. Among zirconium implants, those with an intermediate Ra value showed a significantly higher BIC compared with low and high Ra implants 4 months after surgery. Regarding osseointegration, titanium and zirconium showed equal properties. Cylindric implant design and intermediate surface roughness seemed to enhance osseointegration. Copyright © 2013 Elsevier Inc. All rights reserved.

Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm.

PubMed

Schievink, Wouter I; Palestrant, David; Maya, M Marcel; Rappard, George

2009-03-01

Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray-white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.

Awake craniotomy in a developmentally delayed blind man with cognitive deficits.

PubMed

Burbridge, Mark; Raazi, Mateen

2013-04-01

To describe the complex perioperative considerations and anesthetic management of a cognitively delayed blind adult male who underwent awake craniotomy to remove a left anterior temporal lobe epileptic focus. A 28-yr-old left-handed blind cognitively delayed man was scheduled for awake craniotomy to resect a left anterior temporal lobe epileptic focus due to intractable epilepsy despite multiple medications. His medical history was also significant for retinopathy of prematurity that rendered him legally blind in both eyes and an intracerebral hemorrhage shortly after birth that resulted in a chronic brain injury and developmental delay. His cognitive capacity was comparable with that of an eight year old. Since patient cooperation was the primary concern during the awake electrocorticography phase of surgery, careful assessment of the patient's ability to tolerate the procedure was undertaken. There was extensive planning between surgeons and anesthesiologists, and a patient-specific pharmacological strategy was devised to facilitate surgery. The operation proceeded without complication, the patient has remained seizure-free since the procedure, and his quality of life has improved dramatically. This case shows that careful patient assessment, effective interdisciplinary communication, and a carefully tailored anesthetic strategy can facilitate an awake craniotomy in a potentially uncooperative adult patient with diminished mental capacity and sensory deficits.

Factors affecting profitability for craniotomy.

PubMed

Popp, A John; Scrime, Todd; Cohen, Benjamin R; Feustel, Paul J; Petronis, Karen; Habiniak, Sharon; Waldman, John B; Vosburgh, Margaret M

2002-04-15

The authors studied factors influencing hospital profitability after craniotomy in patients who underwent craniotomy coded as diagnosis-related group (DRG) 1 (17 years of age with nontraumatic disease without complication) and who met their hospital's craniotomy pathway criteria and had a hospital length of stay 4 days or less during a 20-month period. Data in all patients meeting these criteria (76 cases) were collected and collated from various hospital databases. Twenty-one cases were profitable and 55 were not. Variables traditionally influencing cost of care, such as surgeon, procedure, length of operation, and pharmacy use had no significant effect on whether a patient was profitable. The most important influence on profitability was the individual payor. Cases in which care was reimbursed under the prospective payment system based on DRGs were nearly always profitable whereas those covered by per diem plans were nearly always nonprofitable. 1) Hospital information systems should be customized to deliver consolidated data for timely analysis of cost of care for individual patients. This information may be useful in negotiating profitable contracts. 2) A clinical pathway was successful in reducing the difference in cost of care between profitable and nonprofitable postcraniotomy cases. 3) In today's health care environment both cost containment and revenue assume importance in determining profitability.

Shampoo after craniotomy: a pilot study.

PubMed

Ireland, Sandra; Carlino, Karen; Gould, Linda; Frazier, Fran; Haycock, Patricia; Ilton, Suzin; Deptuck, Rachel; Bousfield, Brenda; Verge, Donna; Antoni, Karen; MacRae, Louise; Renshaw, Heather; Bialachowski, Ann; Chagnon, Carol; Reddy, Kesava

2007-01-01

The primary goal of this study was to assess the effect of postoperative hair-washing on incision infection and health-related quality of life (HRQOL) in craniotomy patients. The objectives of this study were to 1) determine the effect of postoperative hair-washing on incision infection and HRQOL, 2) provide evidence to support postoperative patient hygienic care, and 3) develop neurosurgical nursing research capacity Does hair-washing 72 hours after craniotomy and before suture or clip removal influence postoperative incision infection and postoperative HRQOL? A prospective cohort of 100 adult patients was randomized to hair-washing 72-hours postoperatively (n = 48), or no hair washing until suture or clip removal (n = 52). At five to -10 days postoperatively, sutures or clips were removed, incisions were assessed using the ASEPSIS Scale (n = 85) and participants were administered the SF-12 Health Survey (n = 71). At 30 days postoperatively, incisions (n = 70) were reassessed. No differences were found between hair-washing and no hair-washing groups for ASEPSIS scores at five to 10 days and 30 days, and total SF-12 scores at five to 10 days postoperatively (p > or = 0.05). Postoperative hair-washing resulted in no increase in incision infection scores or decrease in HRQOL scores when compared to no hair-washing in patients experiencing craniotomy.

If the skull fits: magnetic resonance imaging and microcomputed tomography for combined analysis of brain and skull phenotypes in the mouse

PubMed Central

Blank, Marissa C.; Roman, Brian B.; Henkelman, R. Mark; Millen, Kathleen J.

2012-01-01

The mammalian brain and skull develop concurrently in a coordinated manner, consistently producing a brain and skull that fit tightly together. It is common that abnormalities in one are associated with related abnormalities in the other. However, this is not always the case. A complete characterization of the relationship between brain and skull phenotypes is necessary to understand the mechanisms that cause them to be coordinated or divergent and to provide perspective on the potential diagnostic or prognostic significance of brain and skull phenotypes. We demonstrate the combined use of magnetic resonance imaging and microcomputed tomography for analysis of brain and skull phenotypes in the mouse. Co-registration of brain and skull images allows comparison of the relationship between phenotypes in the brain and those in the skull. We observe a close fit between the brain and skull of two genetic mouse models that both show abnormal brain and skull phenotypes. Application of these three-dimensional image analyses in a broader range of mouse mutants will provide a map of the relationships between brain and skull phenotypes generally and allow characterization of patterns of similarities and differences. PMID:22947655

Skull Defects in Finite Element Head Models for Source Reconstruction from Magnetoencephalography Signals

PubMed Central

Lau, Stephan; Güllmar, Daniel; Flemming, Lars; Grayden, David B.; Cook, Mark J.; Wolters, Carsten H.; Haueisen, Jens

2016-01-01

Magnetoencephalography (MEG) signals are influenced by skull defects. However, there is a lack of evidence of this influence during source reconstruction. Our objectives are to characterize errors in source reconstruction from MEG signals due to ignoring skull defects and to assess the ability of an exact finite element head model to eliminate such errors. A detailed finite element model of the head of a rabbit used in a physical experiment was constructed from magnetic resonance and co-registered computer tomography imaging that differentiated nine tissue types. Sources of the MEG measurements above intact skull and above skull defects respectively were reconstructed using a finite element model with the intact skull and one incorporating the skull defects. The forward simulation of the MEG signals reproduced the experimentally observed characteristic magnitude and topography changes due to skull defects. Sources reconstructed from measured MEG signals above intact skull matched the known physical locations and orientations. Ignoring skull defects in the head model during reconstruction displaced sources under a skull defect away from that defect. Sources next to a defect were reoriented. When skull defects, with their physical conductivity, were incorporated in the head model, the location and orientation errors were mostly eliminated. The conductivity of the skull defect material non-uniformly modulated the influence on MEG signals. We propose concrete guidelines for taking into account conducting skull defects during MEG coil placement and modeling. Exact finite element head models can improve localization of brain function, specifically after surgery. PMID:27092044

Efficacy of immediate replacement of cranial bone graft following drainage of intracranial empyema.

PubMed

Lajthia, Orgest; Chao, Jerry W; Mandelbaum, Max; Myseros, John S; Oluigbo, Chima; Magge, Suresh N; Zarella, Christopher S; Oh, Albert K; Rogers, Gary F; Keating, Robert F

2018-06-22

OBJECTIVE Intracranial empyema is a life-threatening condition associated with a high mortality rate and residual deleterious neurological effects if not diagnosed and managed promptly. The authors present their institutional experience with immediate reimplantation of the craniotomy flap and clarify the success of this method in terms of cranial integrity, risk of recurrent infection, and need for secondary procedures. METHODS A retrospective analysis of patients admitted for management of intracranial empyema during a 19-year period (1997-2016) identified 33 patients who underwent emergency drainage and decompression with a follow-up duration longer than 6 months, 23 of whom received immediate bone replacement. Medical records were analyzed for demographic information, extent and location of the infection, bone flap size, fixation method, need for further operative intervention, and duration of intravenous antibiotics. RESULTS The mean patient age at surgery was 8.7 ± 5.7 years and the infections were largely secondary to sinusitis (52.8%), with the most common location being the frontal/temporal region (61.3%). Operative intervention involved removal of a total of 31 bone flaps with a mean surface area of 22.8 ± 26.9 cm 2 . Nearly all (96.8%) of the bone flaps replaced at the time of the initial surgery were viable over the long term. Eighteen patients (78.3%) required a single craniotomy in conjunction with antibiotic therapy to address the infection, whereas the remaining 21.7% required more than 1 surgery. Partial bone flap resorption was noted in only 1 (3.2%) of the 31 successfully replaced bone flaps. This patient eventually had his bone flap removed and received a split-calvaria bone graft. Twenty-one patients (91.3%) received postoperative CT scans to evaluate bone integrity. The mean follow-up duration of the cohort was 43.9 ± 54.0 months. CONCLUSIONS The results of our investigation suggest that immediate replacement and stabilization of the bone flap after craniectomy for drainage of intracranial empyemas has a low risk of recurrent infection and is a safe and effective way to restore bone integrity in most patients.

A Tortuous Process of Surgical Treatment for a Large Calcified Chronic Subdural Hematoma.

PubMed

Li, Huan; Mao, Xiang; Tao, Xiao-Gang; Li, Jing-Sheng; Liu, Bai-Yun; Wu, Zhen

2017-12-01

Calcified chronic subdural hematoma (CCSDH) is a rare disease for which no standard approach to treatment has been established. Reports covering both burr hole trepanation and craniotomy for CCSDH are rare. Furthermore, infection of CCSDH after the burr hole trepanation has not been reported in the literature. A 61-year-old man presented with left frontotemporoparietal CCSDH demonstrated on computed tomography (CT) scan. The patient underwent 2 separate burr hole trepanations with intraoperative irrigation and postoperative drainage. These procedures led to infection of the CCSDH. The patient eventually underwent an open craniotomy to provide complete removal of the hematoma. Owing to the complex contents of a CCSDH, burr hole trepanation cannot adequately drain the hematoma or relieve the mass effect. Craniotomy is a much more reliable approach for achieving complete resection of a CCSDH. Copyright © 2017 Elsevier Inc. All rights reserved.

Epidural Hematoma Complication after Rapid Chronic Subdural Hematoma Evacuation: A Case Report.

PubMed

Akpinar, Aykut; Ucler, Necati; Erdogan, Uzay; Yucetas, Cem Seyho

2015-07-06

Chronic subdural hematoma generally occurs in the elderly. After chronic subdural hematoma evacuation surgery, the development of epidural hematoma is a very rare entity. We report the case of a 41-year-old man with an epidural hematoma complication after chronic subdural hematoma evacuation. Under general anesthesia, the patient underwent a large craniotomy with closed system drainage performed to treat the chronic subdural hematoma. After chronic subdural hematoma evacuation, there was epidural leakage on the following day. Although trauma is the most common risk factor in young CSDH patients, some other predisposing factors may exist. Intracranial hypotension can cause EDH. Craniotomy and drainage surgery can usually resolve the problem. Because of rapid dynamic intracranial changes, epidural leakages can occur. A large craniotomy flap and silicone drainage in the operation area are key safety points for neurosurgeons and hydration is essential.

Growth of the skull in young children in Baotou, China.

PubMed

Hou, Hai-dong; Liu, Ming; Gong, Ke-rui; Shao, Guo; Zhang, Chun-Yang

2014-09-01

There are some controversies about the optimal time to perform skull repair in very young Chinese children because of the rapid skull growth in this stage of life. The purpose of this current study is to describe the characteristics of skull growth and to discuss the optimal time for skull repair in young Chinese children with skull defects. A total of 112 children born in the First Affiliated Hospital of Baotou Medical College were measured for six consecutive years starting in 2006. Cranial length (CL, linear distance between the eyebrows to the pillow tuberosity), cranial width (CW, double-sided linear distance of connection of external auditory canal), ear over the top line (EOTL), the eyebrows-the posterior tuberosity line (EPTL), and head circumference (HC) were measured to describe the skull growth. The most rapid period of skull growth occurs during the first year of life. The second and third most rapid periods are the second and third years, respectively. Then, the skull growth slowed and the values of the skull growth index of 6-year-old children were close to those of adults. Children 0-1 years old should not receive skull repair due to their rapid skull growth. The indexes of children 3 years old or older were close to those of the adult; therefore, 3 years old or older may receive skull repair.

Skull base, orbits, temporal bone, and cranial nerves: anatomy on MR imaging.

PubMed

Morani, Ajaykumar C; Ramani, Nisha S; Wesolowski, Jeffrey R

2011-08-01

Accurate delineation, diagnosis, and treatment planning of skull base lesions require knowledge of the complex anatomy of the skull base. Because the skull base cannot be directly evaluated, imaging is critical for the diagnosis and management of skull base diseases. Although computed tomography (CT) is excellent for outlining the bony detail, magnetic resonance (MR) imaging provides better soft tissue detail and is helpful for evaluating the adjacent meninges, brain parenchyma, and bone marrow of the skull base. Thus, CT and MR imaging are often used together for evaluating skull base lesions. This article focuses on the radiologic anatomy of the skull base pertinent to MR imaging evaluation. Copyright © 2011 Elsevier Inc. All rights reserved.

Device and method for skull-melting depth measurement

DOEpatents

Lauf, R.J.; Heestand, R.L.

1993-02-09

A method of skull-melting comprises the steps of: (a) providing a vessel adapted for a skull-melting process, the vessel having an interior, an underside, and an orifice connecting the interior and the underside; (b) disposing a waveguide in the orifice so that the waveguide protrudes sufficiently into the interior to interact with the skull-melting process; (c) providing a signal energy transducer in signal communication with the waveguide; (d) introducing into the vessel a molten working material; (e) carrying out the skull-melting process so that a solidified skull of the working material is formed, the skull and the vessel having an interface therebetween, the skull becoming fused to the waveguide so the signal energy can be transmitted through the waveguide and the skull without interference from the interface; (f) activating the signal energy transducer so that a signal is propagated through the waveguide; and, (g) controlling at least one variable of the skull-melting process utilizing feedback information derived from the propagated signal energy.

Device and method for skull-melting depth measurement

DOEpatents

Lauf, Robert J.; Heestand, Richard L.

1993-01-01

A method of skull-melting comprises the steps of: a. providing a vessel adapted for a skull-melting process, the vessel having an interior, an underside, and an orifice in connecting the interior and the underside; b. disposing a waveguide in the orifice so that the waveguide protrudes sufficiently into the interior to interact with the skull-melting process; c. providing a signal energy transducer in signal communication with the waveguide; d. introducing into the vessel a molten working material; e. carrying out the skull-melting process so that a solidified skull of the working material is formed, the skull and the vessel having an interface therebetween, the skull becoming fused to the waveguide so the signal energy can be transmitted through the waveguide and the skull without interference from the interface; f. activating the signal energy transducer so that a signal is propagated through the waveguide; and, g. controlling at least one variable of the skull-melting process utilizing feedback information derived from the propagated signal energy.

Immediate, but Not Delayed, Microsurgical Skull Reconstruction Exacerbates Brain Damage in Experimental Traumatic Brain Injury Model

PubMed Central

Lau, Tsz; Kaneko, Yuji; van Loveren, Harry; Borlongan, Cesario V.

2012-01-01

Moderate to severe traumatic brain injury (TBI) often results in malformations to the skull. Aesthetic surgical maneuvers may offer normalized skull structure, but inconsistent surgical closure of the skull area accompanies TBI. We examined whether wound closure by replacement of skull flap and bone wax would allow aesthetic reconstruction of the TBI-induced skull damage without causing any detrimental effects to the cortical tissue. Adult male Sprague-Dawley rats were subjected to TBI using the controlled cortical impact (CCI) injury model. Immediately after the TBI surgery, animals were randomly assigned to skull flap replacement with or without bone wax or no bone reconstruction, then were euthanized at five days post-TBI for pathological analyses. The skull reconstruction provided normalized gross bone architecture, but 2,3,5-triphenyltetrazolium chloride and hematoxylin and eosin staining results revealed larger cortical damage in these animals compared to those that underwent no surgical maneuver at all. Brain swelling accompanied TBI, especially the severe model, that could have relieved the intracranial pressure in those animals with no skull reconstruction. In contrast, the immediate skull reconstruction produced an upregulation of the edema marker aquaporin-4 staining, which likely prevented the therapeutic benefits of brain swelling and resulted in larger cortical infarcts. Interestingly, TBI animals introduced to a delay in skull reconstruction (i.e., 2 days post-TBI) showed significantly reduced edema and infarcts compared to those exposed to immediate skull reconstruction. That immediate, but not delayed, skull reconstruction may exacerbate TBI-induced cortical tissue damage warrants a careful consideration of aesthetic repair of the skull in TBI. PMID:22438975

A testbed for optimizing electrodes embedded in the skull or in artificial skull replacement pieces used after injury

PubMed Central

Jiang, JingLe; Marathe, Amar R.; Keene, Jennifer C.; Taylor, Dawn M.

2016-01-01

Background Custom-fitted skull replacement pieces are often used after a head injury or surgery to replace damaged bone. Chronic brain recordings are beneficial after injury/surgery for monitoring brain health and seizure development. Embedding electrodes directly in these artificial skull replacement pieces would be a novel, low-risk way to perform chronic brain monitoring in these patients. Similarly, embedding electrodes directly in healthy skull would be a viable minimally-invasive option for many other neuroscience and neurotechnology applications requiring chronic brain recordings. New Method We demonstrate a preclinical testbed that can be used for refining electrode designs embedded in artificial skull replacement pieces or for embedding directly into the skull itself. Options are explored to increase the surface area of the contacts without increasing recording contact diameter to maximize recording resolution. Results Embedding electrodes in real or artificial skull allows one to lower electrode impedance without increasing the recording contact diameter by making use of conductive channels that extend into the skull. The higher density of small contacts embedded in the artificial skull in this testbed enables one to optimize electrode spacing for use in real bone. Comparison with Existing Methods For brain monitoring applications, skull-embedded electrodes fill a gap between electroencephalograms recorded on the scalp surface and the more invasive epidural or subdural electrode sheets. Conclusions Embedding electrodes into the skull or in skull replacement pieces may provide a safe, convenient, minimally-invasive alternative for chronic brain monitoring. The manufacturing methods described here will facilitate further testing of skull-embedded electrodes in animal models. PMID:27979758

A testbed for optimizing electrodes embedded in the skull or in artificial skull replacement pieces used after injury.

PubMed

Jiang, JingLe; Marathe, Amar R; Keene, Jennifer C; Taylor, Dawn M

2017-02-01

Custom-fitted skull replacement pieces are often used after a head injury or surgery to replace damaged bone. Chronic brain recordings are beneficial after injury/surgery for monitoring brain health and seizure development. Embedding electrodes directly in these artificial skull replacement pieces would be a novel, low-risk way to perform chronic brain monitoring in these patients. Similarly, embedding electrodes directly in healthy skull would be a viable minimally-invasive option for many other neuroscience and neurotechnology applications requiring chronic brain recordings. We demonstrate a preclinical testbed that can be used for refining electrode designs embedded in artificial skull replacement pieces or for embedding directly into the skull itself. Options are explored to increase the surface area of the contacts without increasing recording contact diameter to maximize recording resolution. Embedding electrodes in real or artificial skull allows one to lower electrode impedance without increasing the recording contact diameter by making use of conductive channels that extend into the skull. The higher density of small contacts embedded in the artificial skull in this testbed enables one to optimize electrode spacing for use in real bone. For brain monitoring applications, skull-embedded electrodes fill a gap between electroencephalograms recorded on the scalp surface and the more invasive epidural or subdural electrode sheets. Embedding electrodes into the skull or in skull replacement pieces may provide a safe, convenient, minimally-invasive alternative for chronic brain monitoring. The manufacturing methods described here will facilitate further testing of skull-embedded electrodes in animal models. Published by Elsevier B.V.

A prospective, randomized, double-blind, and multicenter trial of prophylactic effects of ramosetronon postoperative nausea and vomiting (PONV) after craniotomy: comparison with ondansetron

PubMed Central

2014-01-01

Background Craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). This prospective, randomized, double-blind, multi-center study was performed to evaluate the efficacy of prophylactic ramosetron in preventing PONV compared with ondansetron after elective craniotomy in adult patients. Methods A total of 160 American Society of Anesthesiologists physical status I–II patients aged 19–65 years who were scheduled to undergo elective craniotomy for various intracranial lesions were enrolled in this study. All patients received total intravenous anesthesia (TIVA) with propofol and remifentanil. Patients were randomly allocated into three groups to receive ondansetron (4 mg; group A, n  =  55), ondansetron (8 mg; group B, n  =  54), or ramosetron (0.3 mg; group C, n  =  51) intravenously at the time of dural closure. The incidence of PONV, the need for rescue antiemetics, pain score, patient-controlled analgesia (PCA) consumption, and adverse events were recorded 48 h postoperatively. Results Among the initial 160 patients, 127 completed the study and were included in the final analysis. The incidences of PONV were lower (nausea, 14% vs. 59% and 41%, respectively; P  <  0.001; vomiting, P  =  0.048) and the incidence of complete response was higher (83% vs. 37% and 59%, respectively; P  <  0.001) in group C than in groups A and B at 48 h postoperatively. There were no significant differences in the incidence of PONV or need for rescue antiemetics 0–2 h postoperatively, but significant differences were observed in the incidence of PONV and complete response among the three groups 2–48 h postoperatively. No statistically significant intergroup differences were observed in postoperative pain, PCA consumption, or adverse events. Conclusion Intravenous administration of ramosetron at 0.3 mg reduced the incidence of PONV and rescue antiemetic requirement in craniotomy patients. Ramosetron at 0.3 mg was more effective than ondansetron at 4 or 8 mg for preventing PONV in adult craniotomy patients. Trial registration Clinical Research Information Service (CRiS) Identifier: KCT0000320. Registered 9 January 2012. PMID:25104916

Skull defect reconstruction based on a new hybrid level set.

PubMed

Zhang, Ziqun; Zhang, Ran; Song, Zhijian

2014-01-01

Skull defect reconstruction is an important aspect of surgical repair. Historically, a skull defect prosthesis was created by the mirroring technique, surface fitting, or formed templates. These methods are not based on the anatomy of the individual patient's skull, and therefore, the prosthesis cannot precisely correct the defect. This study presented a new hybrid level set model, taking into account both the global optimization region information and the local accuracy edge information, while avoiding re-initialization during the evolution of the level set function. Based on the new method, a skull defect was reconstructed, and the skull prosthesis was produced by rapid prototyping technology. This resulted in a skull defect prosthesis that well matched the skull defect with excellent individual adaptation.

Implant-retained skull prosthesis to cover a large defect of the hairy skull resulting from treatment of a basal cell carcinoma: A clinical report.

PubMed

Hoekstra, Jitske; Vissink, Arjan; Raghoebar, Gerry M; Visser, Anita

2017-05-01

Skin carcinoma, particularly basal cell carcinoma, and its treatment can result in large defects of the hairy skull. A 53-year-old man is described who was surgically treated for a large basal cell carcinoma invading the skin and underlying tissue at the top of the hairy skull. Treatment consisted of resecting the tumor and external part of the skull bone. To protect the brain and to cover the defect of the hairy skull, an acrylic resin skull prosthesis with hair was designed to mask the defect. The skull prosthesis was retained on 8 extraoral implants placed at the margins of the defect in the skull bone. The patient was satisfied with the treatment outcome. Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.

Dimensional, Geometrical, and Physical Constraints in Skull Growth.

PubMed

Weickenmeier, Johannes; Fischer, Cedric; Carter, Dennis; Kuhl, Ellen; Goriely, Alain

2017-06-16

After birth, the skull grows and remodels in close synchrony with the brain to allow for an increase in intracranial volume. Increase in skull area is provided primarily by bone accretion at the sutures. Additional remodeling, to allow for a change in curvatures, occurs by resorption on the inner surface of the bone plates and accretion on their outer surfaces. When a suture fuses too early, normal skull growth is disrupted, leading to a deformed final skull shape. The leading theory assumes that the main stimulus for skull growth is provided by mechanical stresses. Based on these ideas, we first discuss the dimensional, geometrical, and kinematic synchrony between brain, skull, and suture growth. Second, we present two mechanical models for skull growth that account for growth at the sutures and explain the various observed dysmorphologies. These models demonstrate the particular role of physical and geometrical constraints taking place in skull growth.

Dimensional, Geometrical, and Physical Constraints in Skull Growth

NASA Astrophysics Data System (ADS)

Weickenmeier, Johannes; Fischer, Cedric; Carter, Dennis; Kuhl, Ellen; Goriely, Alain

2017-06-01

After birth, the skull grows and remodels in close synchrony with the brain to allow for an increase in intracranial volume. Increase in skull area is provided primarily by bone accretion at the sutures. Additional remodeling, to allow for a change in curvatures, occurs by resorption on the inner surface of the bone plates and accretion on their outer surfaces. When a suture fuses too early, normal skull growth is disrupted, leading to a deformed final skull shape. The leading theory assumes that the main stimulus for skull growth is provided by mechanical stresses. Based on these ideas, we first discuss the dimensional, geometrical, and kinematic synchrony between brain, skull, and suture growth. Second, we present two mechanical models for skull growth that account for growth at the sutures and explain the various observed dysmorphologies. These models demonstrate the particular role of physical and geometrical constraints taking place in skull growth.

Von Hippel-Lindau Disease: A Rare Familiar Multi-System Disorder and the Impact of the Clinical Nurse Specialist

DTIC Science & Technology

1993-01-01

would undergo removal of both adrenal glands, the renal cell carcinomas, a cholecystectomy and a choledochoduodenostomy for biliary drainage . The...bleeding, renal failure, and pancreatitis. After recovery, a craniotomy would be done to remove the hemangioblastoma that had been bleeding. The...analgesia. After a three month convalescence, the patient had a craniotomy and was home within a week. The patient’s siblings have all had negative eye

Use of the Abdominal Aortic Tourniquet for Hemorrhage Control

DTIC Science & Technology

2013-10-01

simulate an epidural hematoma) using a bone drill to access the epidural space via a craniotomy and then use a small bladder and fill with fluid. We would...external pressure transducer and CSF drainage system. The catheter will be sutured in place and a nonocclusive dressing applied. The catheter will...diameter in relation to ICP. Craniotomy . A midline incision from the level of lateral canthi to 4-7cm past the external occipital protuberance will be

Evaluation of SOCOM Wireless Monitor in Trauma Patients

DTIC Science & Technology

2016-02-01

the need for craniotomy in the absence of neurologic change. J Trauma Acute Care Surg 2013 Apr;74(4):967-75. 35) Thorson CM, Van Haren RM, Ryan...Guarch GA, Hanna M, Allen CJ, Ray JJ, Schulman CI, Proctor KG, Sleeman D, Namias N: Need for percutaneous drainage after cholecystectomy is higher in...Repeat head CT after minimal brain injury predicts need for craniotomy in absence of neurologic change. a. Presented at 71rst Annual Meeting of

Should epidural drain be recommended after supratentorial craniotomy for epileptic patients?

PubMed

Guangming, Zhang; Huancong, Zuo; Wenjing, Zhou; Guoqiang, Chen; Xiaosong, Wang

2009-08-01

ED was once and is still commonly applied to prevent mainly EH and subgaleal CSF collection. We designed this study to observe if ED could decrease the incidence and volume of EH and subgaleal CSF collection after supratentorial craniotomy in epileptic patients. Three hundred forty-two epileptic patients were divided into 2 groups according to their first craniotomy date (group 1 in odd date and group 2 in even date). Patients in group 1 had ED and those in group 2 had no ED. The patient numbers and volumes of EH and subgaleal CSF collections in both groups were recorded and statistically analyzed. There were 22 EHs in group 1 and 20 EHs in group 2. There were 11 and 10 subgaleal CSF collections in groups 1 and 2, respectively. The average volume of EH was 13.5 +/- 8.12 and 14.65 +/- 7.72 mL in groups 1 and 2, respectively. The average volume of subgaleal CSF collection was 42.76 +/- 12.09 and 43.75 +/- 11.44 mL in groups 1 and 2, respectively. There were no statistical differences in the incidence and average volume of EH and subgaleal CSF collection between the 2 groups. ED cannot decrease the incidence and volume of EH and subgaleal CSF collection. ED should not be recommended after supratentorial epileptic craniotomy.

[Risk factors for surgical site infections in patients undergoing craniotomy].

PubMed

Cha, Kyeong-Sook; Cho, Ok-Hee; Yoo, So-Yeon

2010-04-01

The objectives of this study were to determine the prevalence, incidence, and risk factors for postoperative surgical site infections (SSIs) after craniotomy. This study was a retrospective case-control study of 103 patients who had craniotomies between March 2007 and December 2008. A retrospective review of prospectively collected databases of consecutive patients who underwent craniotomy was done. SSIs were defined by using the Centers for Disease Control criteria. Twenty-six cases (infection) and 77 controls (no infection) were matched for age, gender and time of surgery. Descriptive analysis, t-test, X(2)-test and logistic regression analyses were used for data analysis. The statistical difference between cases and controls was significant for hospital length of stay (>14 days), intensive care unit stay more than 15 days, Glasgrow Coma Scale (GCS) score (< or = 7 days), extra-ventricular drainage and coexistent infection. Risk factors were identified by logistic regression and included hospital length of stay of more than 14 days (odds ratio [OR]=23.39, 95% confidence interval [CI]=2.53-216.11) and GCS score (< or = 7 scores) (OR=4.71, 95% CI=1.64-13.50). The results of this study show that patients are at high risk for infection when they have a low level of consciousness or their length hospital stay is long term. Nurses have to take an active and continuous approach to infection control to help with patients having these risk factors.

Efficacy and safety of key hole craniotomy for the evacuation of spontaneous cerebellar hemorrhage.

PubMed

Tokimura, Hiroshi; Tajitsu, Kenichiro; Taniguchi, Ayumi; Yamahata, Hitoshi; Tsuchiya, Masahiro; Takayama, Kenji; Shinsato, Tomomi; Arita, Kazunori

2010-01-01

The efficacy and safety of cerebellar hemorrhage evacuation by key hole craniotomy and the importance of thorough evacuation and irrigation of the hematoma in the fourth ventricle to resolve obstructive hydrocephalus were assessed in 23 patients with spontaneous cerebellar hemorrhage (SCH) greater than 3 cm or with brainstem compression and hydrocephalus. A 5-cm elongated S-shaped scalp incision was made, and a 3-cm key hole craniotomy was performed over a cerebellar convexity area. The hematoma was immediately evacuated through a small corticotomy. The hematoma in the fourth ventricle was gently removed through the hematoma cavity, followed by thorough saline irrigation to release obstructive hydrocephalus. Patients classified retrospectively into favorable and poor outcome groups using the Glasgow Outcome Scale (GOS) scores of 4-5 vs. 1-3 showed significant differences with respect to the preoperative Glasgow Coma Scale, hematoma size and volume, and brainstem compression. Only 2 of the 23 patients required ventricular drainage and no postoperative complications were recorded. Patients treated by experienced and inexperienced surgeons showed no significant differences in the hematoma evacuation rate, postoperative GOS, and interval from skin incision to start of hematoma evacuation. Our simplified method of key hole craniotomy to treat SCH was less invasive but easy to perform, as even inexperienced neurosurgeons could obtain good surgical results. Thorough cleaning of the fourth ventricle minimized the necessity for ventricular drainage.

Transcranial Near-Infrared Laser Transmission (NILT) Profiles (800 nm): Systematic Comparison in Four Common Research Species

PubMed Central

Lapchak, Paul A.; Boitano, Paul D.; Butte, Pramod V.; Fisher, David J.; Hölscher, Thilo; Ley, Eric J.; Nuño, Miriam; Voie, Arne H.; Rajput, Padmesh S.

2015-01-01

Background and Purpose Transcranial near-infrared laser therapy (TLT) is a promising and novel method to promote neuroprotection and clinical improvement in both acute and chronic neurodegenerative diseases such as acute ischemic stroke (AIS), traumatic brain injury (TBI), and Alzheimer’s disease (AD) patients based upon efficacy in translational animal models. However, there is limited information in the peer-reviewed literature pertaining to transcranial near-infrared laser transmission (NILT) profiles in various species. Thus, in the present study we systematically evaluated NILT characteristics through the skull of 4 different species: mouse, rat, rabbit and human. Results Using dehydrated skulls from 3 animal species, using a wavelength of 800nm and a surface power density of 700 mW/cm2, NILT decreased from 40.10% (mouse) to 21.24% (rat) to 11.36% (rabbit) as skull thickness measured at bregma increased from 0.44 mm in mouse to 0.83 mm in rat and then 2.11 mm in rabbit. NILT also significantly increased (p<0.05) when animal skulls were hydrated (i.e. compared to dehydrated); but there was no measurable change in thickness due to hydration. In human calvaria, where mean thickness ranged from 7.19 mm at bregma to 5.91 mm in the parietal skull, only 4.18% and 4.24% of applied near-infrared light was transmitted through the skull. There was a slight (9.2-13.4%), but insignificant effect of hydration state on NILT transmission of human skulls, but there was a significant positive correlation between NILT and thickness at bregma and parietal skull, in both hydrated and dehydrated states. Conclusion This is the first systematic study to demonstrate differential NILT through the skulls of 4 different species; with an inverse relationship between NILT and skull thickness. With animal skulls, transmission profiles are dependent upon the hydration state of the skull, with significantly greater penetration through hydrated skulls compared to dehydrated skulls. Using human skulls, we demonstrate a significant correlation between thickness and penetration, but there was no correlation with skull density. The results suggest that TLT should be optimized in animals using novel approaches incorporating human skull characteristics, because of significant variance of NILT profiles directly related to skull thickness. PMID:26039354

Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique.

PubMed

Tayebi Meybodi, Ali; Lawton, Michael T; Yousef, Sonia; Guo, Xiaoming; González Sánchez, Jose Juan; Tabani, Halima; García, Sergio; Burkhardt, Jan-Karl; Benet, Arnau

2018-02-23

Anterior clinoidectomy is a difficult yet essential technique in skull base surgery. Two main techniques (extradural and intradural) with multiple modifications have been proposed to increase efficiency and avoid complications. In this study, the authors sought to develop a hybrid technique based on localization of the optic strut (OS) to combine the advantages and avoid the disadvantages of both techniques. Ten cadaveric specimens were prepared for surgical simulation. After a standard pterional craniotomy, the anterior clinoid process (ACP) was resected in 2 steps. The segment anterior to the OS was resected extradurally, while the segment posterior to the OS was resected intradurally. The proposed technique was performed in 6 clinical cases to evaluate its safety and efficiency. Anterior clinoidectomy was successfully performed in all cadaveric specimens and all 6 patients by using the proposed technique. The extradural phase enabled early decompression of the optic nerve while avoiding the adjacent internal carotid artery. The OS was drilled intradurally under direct visualization of the adjacent neurovascular structures. The described landmarks were easily identifiable and applicable in the surgically treated patients. No operative complication was encountered. A proposed 2-step hybrid technique combines the advantages of the extradural and intradural techniques while avoiding their disadvantages. This technique allows reduced intradural drilling and subarachnoid bone dust deposition. Moreover, the most critical part of the clinoidectomy-that is, drilling of the OS and removal of the body of the ACP-is left for the intradural phase, when critical neurovascular structures can be directly viewed.

Three-dimensional intraoperative ultrasound of vascular malformations and supratentorial tumors.

PubMed

Woydt, Michael; Horowski, Anja; Krauss, Juergen; Krone, Andreas; Soerensen, Niels; Roosen, Klaus

2002-01-01

The benefits and limits of a magnetic sensor-based 3-dimensional (3D) intraoperative ultrasound technique during surgery of vascular malformations and supratentorial tumors were evaluated. Twenty patients with 11 vascular malformations and 9 supratentorial tumors undergoing microsurgical resection or clipping were investigated with an interactive magnetic sensor data acquisition system allowing freehand scanning. An ultrasound probe with a mounted sensor was used after craniotomies to localize lesions, outline tumors or malformation margins, and identify supplying vessels. A 3D data set was obtained allowing reformation of multiple slices in all 3 planes and comparison to 2-dimensional (2D) intraoperative ultrasound images. Off-line gray-scale segmentation analysis allowed differentiation between tissue with different echogenicities. Color-coded information about blood flow was extracted from the images with a reconstruction algorithm. This allowed photorealistic surface displays of perfused tissue, tumor, and surrounding vessels. Three-dimensional intraoperative ultrasound data acquisition was obtained within 5 minutes. Off-line analysis and reconstruction time depends on the type of imaging display and can take up to 30 minutes. The spatial relation between aneurysm sac and surrounding vessels or the skull base could be enhanced in 3 out of 6 aneurysms with 3D intraoperative ultrasound. Perforating arteries were visible in 3 cases only by using 3D imaging. 3D ultrasound provides a promising imaging technique, offering the neurosurgeon an intraoperative spatial orientation of the lesion and its vascular relationships. Thereby, it may improve safety of surgery and understanding of 2D ultrasound images.

Validation of a stereo camera system to quantify brain deformation due to breathing and pulsatility.

PubMed

Faria, Carlos; Sadowsky, Ofri; Bicho, Estela; Ferrigno, Giancarlo; Joskowicz, Leo; Shoham, Moshe; Vivanti, Refael; De Momi, Elena

2014-11-01

A new stereo vision system is presented to quantify brain shift and pulsatility in open-skull neurosurgeries. The system is endowed with hardware and software synchronous image acquisition with timestamp embedding in the captured images, a brain surface oriented feature detection, and a tracking subroutine robust to occlusions and outliers. A validation experiment for the stereo vision system was conducted against a gold-standard optical tracking system, Optotrak CERTUS. A static and dynamic analysis of the stereo camera tracking error was performed tracking a customized object in different positions, orientations, linear, and angular speeds. The system is able to detect an immobile object position and orientation with a maximum error of 0.5 mm and 1.6° in all depth of field, and tracking a moving object until 3 mm/s with a median error of 0.5 mm. Three stereo video acquisitions were recorded from a patient, immediately after the craniotomy. The cortical pulsatile motion was captured and is represented in the time and frequency domain. The amplitude of motion of the cloud of features' center of mass was inferior to 0.8 mm. Three distinct peaks are identified in the fast Fourier transform analysis related to the sympathovagal balance, breathing, and blood pressure with 0.03-0.05, 0.2, and 1 Hz, respectively. The stereo vision system presented is a precise and robust system to measure brain shift and pulsatility with an accuracy superior to other reported systems.

Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases.

PubMed Central

Wadley, J.; Dorward, N.; Kitchen, N.; Thomas, D.

1999-01-01

Operative neurosurgery has recently entered an exciting era of image guided surgery or neuronavigation and application of this novel technology is beginning to have a significant impact in many ways in a variety of intracranial procedures. In order to fully assess the advantages of image guided techniques over conventional planning and surgery in selected cases, detailed prospective evaluation has been carried out during the advanced development of an optically tracked neuronavigation system. Over a 2-year period, 300 operative neurosurgical procedures have been performed with the assistance of interactive image guidance, as well as the development of new software applications and hardware tools. A broad range of intracranial neurosurgical procedures were seen to benefit from image guidance, including 163 craniotomies, 53 interactive stereotactic biopsies, 7 tracked neuroendoscopies and 37 complex skull base procedures. The most common pathological diagnoses were cerebral glioma in 98 cases, meningioma in 64 and metastasis in 23. Detailed analysis of a battery of postoperative questions revealed benefits in operative planning, appreciation of anatomy, lesion location, safety of surgery and greatly enhanced surgical confidence. The authors believe that image guided surgical technology, with new developments such as those described, has a significant role to play in contemporary neurosurgery and its widespread adoption in practice will be realised in the near future. Images Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 PMID:10615186

Symptomatic Acute-on-Chronic Subdural Hematoma: A Clinicopathological Study.

PubMed

Castellani, Rudy J; Mojica-Sanchez, Gruschenka; Schwartzbauer, Gary; Hersh, David S

2017-06-01

The pathophysiology of acute-on-chronic subdural hematoma (ACSDH) is complex and incompletely understood. Evidence to date indicates that the overall process is initiated by rotational force with movement of the brain inside the skull, which exerts tensile strain and rupture of bridging veins, leading in turn to acute hemorrhage in the subdural potential space. This is followed by the proliferation of mesenchymal elements with angiogenesis and inflammation, which in turn becomes a substrate for repeated hemorrhage and expansion of the lesion. Given the prevalence of traumatic subdural processes in the forensic setting and the importance of proper assessment of timing, etiology, risk factors, and clinicopathological correlation, we studied 47 patients presenting to the University of Maryland Shock Trauma Center, all of whom underwent craniotomy with resection of the outer membrane due to symptomatic ACSDH. The surgically resected tissue was examined for histopathologic features in all cases. Our findings highlight that ACSDH is a condition precipitated by trauma that affects middle-aged and older adults, is relatively indolent, is unilateral or asymmetric, and has a low in-hospital mortality rate. Pathological analysis demonstrates a substantial outer membrane in all cases with varying degrees of inflammation and organization that cannot be precisely dated as a function of clinical presentation. The extrapolation of adult ACSDH to mixed acute and chronic subdural hemorrhage in the pediatric setting is problematic due to substantial differences in clinical presentation, severity of underlying brain injury, gross and microscopic findings, and outcome.

Preconquest Peruvian neurosurgeons: a study of Inca and pre-Columbian trephination and the art of medicine in ancient Peru.

PubMed

Marino, R; Gonzales-Portillo, M

2000-10-01

Trephination and craniotomy performed by abrasion, scraping, crosscut sawing, and drilling are the oldest known surgical techniques used by primitive peoples. As a result of archaeological findings, the human skull is the most frequently studied part of the excavated body, leading to the creation of a new aspect of anthropology known as "cultural osteology." Found in ancient tombs, the human remains, mummies, skeletons, and their belongings, including war instruments, pottery, clothing, jewels, and surgical instruments, constitute the richest source of insight into the lives and pragmatic activities of ancient cultures. This study summarizes thousands of years of pre-Columbian history and medical evolution, specifically in the early and primitive practice of trephination, as precursors of neurosurgery. Comparative osteology studies have demonstrated that using primitive stone or metal instruments, the sirkaks (Inca surgeons) achieved an average survival rate of 50 to 70% of their craniectomy patients, with little incidence of infection or other complications. Despite their rudimentary knowledge of disease and pathology, a considerable knowledge of anatomy and natural medicine provided them with hemostatic agents, antiseptics, and other medical drugs, such as quinine for fever and malaria, as well as gold, silver, and other products to perform cranioplasties. Living in a world of continuous hand-to-hand combat, they also developed aggressive and defensive weapons that necessitated refinement of surgical techniques to save soldiers from battle wounds to their poorly protected crania.

Transcranial and Epidural Approach for Spontaneous Cerebrospinal Fluid Leakage Due to Meningoencephalocele of the Lateral Sphenoid Sinus.

PubMed

Shintoku, Ryosuke; Tosaka, Masahiko; Shimizu, Tatsuya; Yoshimoto, Yuhei

2018-01-01

We experienced a case of sphenoid sinus type meningoencephalocele manifesting as severe cerebrospinal fluid (CSF) rhinorrhea. A 35-year-old man became aware of serous nasal discharge 1 year previously, which had gradually worsened. The nasal discharge was diagnosed as CSF rhinorrhea. Head computed tomography (CT) showed several small depressions in the bone of the left middle cranial fossa, and the largest depression extended through the bone to the lateral sphenoid sinus. Head magnetic resonance imaging revealed that the meningoencephalocele projected to the lateral sphenoid sinus, through this small bone defect of the middle cranial fossa. We performed a combined craniotomy and epidural approach without intradural procedures using neuronavigation. Multiple meningoencephaloceles protruded into small depressions in the middle skull base. The small protrusions not passing through the sphenoid sinus were coagulated. The largest protrusion causing the CSF leakage was identified by neuronavigation. This meningoencephalocele was cut. Both the dural and bone sides were closed with double layers to prevent CSF leakage. The CSF rhinorrhea completely stopped after the surgery. In our case, identification of the leak site was easy with neuronavigation based on bone window CT. The epidural approach also has significant advantages with double layer closure, including both the dural and bone sides. If the site of CSF leakage is outside the foramen rotundum (as with the most common type of lateral sphenoid sinus meningoencephalocele), we recommend the epidural approach using neuronavigation for surgical treatment.

21 CFR 882.4460 - Neurosurgical head holder (skull clamp).

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Neurosurgical head holder (skull clamp). 882.4460... holder (skull clamp). (a) Identification. A neurosurgical head holder (skull clamp) is a device used to clamp the patient's skull to hold head and neck in a particular position during surgical procedures. (b...

21 CFR 882.4750 - Skull punch.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Skull punch. 882.4750 Section 882.4750 Food and... NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4750 Skull punch. (a) Identification. A skull punch is a device used to punch holes through a patient's skull to allow fixation of cranioplasty plates or...

21 CFR 882.4030 - Skull plate anvil.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Skull plate anvil. 882.4030 Section 882.4030 Food... DEVICES NEUROLOGICAL DEVICES Neurological Surgical Devices § 882.4030 Skull plate anvil. (a) Identification. A skull plate anvil is a device used to form alterable skull plates in the proper shape to fit...

Comparison of propofol pharmacokinetic and pharmacodynamic models for awake craniotomy: A prospective observational study.

PubMed

Soehle, Martin; Wolf, Christina F; Priston, Melanie J; Neuloh, Georg; Bien, Christian G; Hoeft, Andreas; Ellerkmann, Richard K

2015-08-01

Anaesthesia for awake craniotomy aims for an unconscious patient at the beginning and end of surgery but a rapidly awakening and responsive patient during the awake period. Therefore, an accurate pharmacokinetic/pharmacodynamic (PK/PD) model for propofol is required to tailor depth of anaesthesia. To compare the predictive performances of the Marsh and the Schnider PK/PD models during awake craniotomy. A prospective observational study. Single university hospital from February 2009 to May 2010. Twelve patients undergoing elective awake craniotomy for resection of brain tumour or epileptogenic areas. Arterial blood samples were drawn at intervals and the propofol plasma concentration was determined. The prediction error, bias [median prediction error (MDPE)] and inaccuracy [median absolute prediction error (MDAPE)] of the Marsh and the Schnider models were calculated. The secondary endpoint was the prediction probability PK, by which changes in the propofol effect-site concentration (as derived from simultaneous PK/PD modelling) predicted changes in anaesthetic depth (measured by the bispectral index). The Marsh model was associated with a significantly (P = 0.05) higher inaccuracy (MDAPE 28.9 ± 12.0%) than the Schnider model (MDAPE 21.5 ± 7.7%) and tended to reach a higher bias (MDPE Marsh -11.7 ± 14.3%, MDPE Schnider -5.4 ± 20.7%, P = 0.09). MDAPE was outside of accepted limits in six (Marsh model) and two (Schnider model) of 12 patients. The prediction probability was comparable between the Marsh (PK 0.798 ± 0.056) and the Schnider model (PK 0.787 ± 0.055), but after adjusting the models to each individual patient, the Schnider model achieved significantly higher prediction probabilities (PK 0.807 ± 0.056, P = 0.05). When using the 'asleep-awake-asleep' anaesthetic technique during awake craniotomy, we advocate using the PK/PD model proposed by Schnider. Due to considerable interindividual variation, additional monitoring of anaesthetic depth is recommended. ClinicalTrials.gov identifier: NCT 01128465.

Comparison of dexmedetomidine and propofol for conscious sedation in awake craniotomy: a prospective, double-blind, randomized, and controlled clinical trial.

PubMed

Shen, She-liang; Zheng, Jia-yin; Zhang, Jun; Wang, Wen-yuan; Jin, Tao; Zhu, Jing; Zhang, Qi

2013-11-01

It has been reported that dexmedetomidine (DEX) can be used for conscious sedation in awake craniotomy, but few data exist to compare DEX versus propofol (PRO). To compare the efficacy and safety of DEX versus PRO for conscious sedation in awake craniotomy. Thirty patients of American Society of Anesthesiologists grade I-II scheduled for awake craniotomy, were randomized into 2 groups each containing 15 subjects. Group D received DEX and group P received PRO. Two minutes after tracheal intubation (T1), PRO (target plasma concentration) was titrated down to 1 to 4 µg/mL in group P. In group D, PRO was discontinued and DEX was administered 1.0 µg/kg followed by a maintenance dose of 0.2 to 0.7 µg/kg/h. The surgeon preset the anticipated awake point-in-time (T0) preoperatively. Ten minutes before T0 (T3), DEX was titrated down to 0.2 µg/kg/h in group D, PRO was discontinued and normal saline (placebo) 5 mL/h was infused in group P. Arousal time, quality of revival and adverse events during the awake period, degree of satisfaction from surgeons and patients were recorded. Arousal time was significantly shorter in group D than in group P (P < .001). The quality of revival during the awake period in group D was similar to that of group P (P = .68). The degree of satisfaction of surgeons was significantly higher in group D than in group P (P < .001), but no difference was found between the 2 groups with respect to patient satisfaction (P = .80). There was no difference between the 2 groups in the incidence of adverse events during the awake period (P > .05). Either DEX or PRO can be effectively and safely used for conscious sedation in awake craniotomy. Comparing the two, DEX produced a shorter arousal time and a higher degree of surgeon satisfaction.

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases.

PubMed

Maldaun, Marcos V C; Khawja, Shumaila N; Levine, Nicholas B; Rao, Ganesh; Lang, Frederick F; Weinberg, Jeffrey S; Tummala, Sudhakar; Cowles, Charles E; Ferson, David; Nguyen, Anh-Thuy; Sawaya, Raymond; Suki, Dima; Prabhu, Sujit S

2014-10-01

The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex. From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome. Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0-13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%). There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

Two- and Three-Dimensional Anatomy of Paranasal Sinuses in Arabian Foals

PubMed Central

BAHAR, Sadullah; BOLAT, Durmus; DAYAN, Mustafa Orhun; PAKSOY, Yahya

2013-01-01

ABSTRACT The 2- and 3-dimensional (3D) anatomy and the morphometric properties of the paranasal sinuses of the foal have received little or no attention in the literature. The aim of this study was to obtain details of the paranasal sinuses using multiplane CT imaging to create 3D models and to determine morphological and morphometric data for the sinuses using the 3D models. The heads of five female foals were used in this study. The heads were scanned using computed tomography (CT) in the rostrocaudal direction. After the heads had been frozen, anatomical sections were obtained in the scan position. The 3D models of sinuses and the skull were prepared using MIMICS®. These models were used to assess the surface area and volume of the sinuses, the width, height and orientation of the apertures connecting these sinuses and finally the planar relation of the sinuses with the skull. The right and left sides of all anatomical structures, except the sphenoid sinuses, had symmetric organization on CT images and anatomical sections. The total sinus surface area and volume on both sides were 214.4 cm2 and 72.9 ml, respectively. The largest and the smallest sinuses were the frontal sinus (41.5 ml) and the middle conchal sinus (0.2 ml), respectively. It was found that the planes bounding the sinuses passed through easily palpable points on the head. In conclusion, 3D modeling in combination with conventional sectional imaging of the paranasal sinuses of the foal may help anatomists, radiologists, clinicians and veterinary students. PMID:24004969

Two- and three-dimensional anatomy of paranasal sinuses in Arabian foals.

PubMed

Bahar, Sadullah; Bolat, Durmus; Dayan, Mustafa Orhun; Paksoy, Yahya

2014-01-01

The 2- and 3-dimensional (3D) anatomy and the morphometric properties of the paranasal sinuses of the foal have received little or no attention in the literature. The aim of this study was to obtain details of the paranasal sinuses using multiplane CT imaging to create 3D models and to determine morphological and morphometric data for the sinuses using the 3D models. The heads of five female foals were used in this study. The heads were scanned using computed tomography (CT) in the rostrocaudal direction. After the heads had been frozen, anatomical sections were obtained in the scan position. The 3D models of sinuses and the skull were prepared using MIMICS(®). These models were used to assess the surface area and volume of the sinuses, the width, height and orientation of the apertures connecting these sinuses and finally the planar relation of the sinuses with the skull. The right and left sides of all anatomical structures, except the sphenoid sinuses, had symmetric organization on CT images and anatomical sections. The total sinus surface area and volume on both sides were 214.4 cm(2) and 72.9 ml, respectively. The largest and the smallest sinuses were the frontal sinus (41.5 ml) and the middle conchal sinus (0.2 ml), respectively. It was found that the planes bounding the sinuses passed through easily palpable points on the head. In conclusion, 3D modeling in combination with conventional sectional imaging of the paranasal sinuses of the foal may help anatomists, radiologists, clinicians and veterinary students.

A new method for selecting auricle positions in skull base reconstruction for temporal bone cancer.

PubMed

Tanaka, Kentaro; Yano, Tomoyuki; Homma, Tsutomu; Tsunoda, Atsunobu; Aoyagi, Masaru; Kishimoto, Seiji; Okazaki, Mutsumi

2018-03-25

In advanced temporal bone carcinoma cases, we attempted to preserve as much of the auricle as possible from a cosmetic and functional perspective. Difficulties are associated with selecting an adequate position for reconstructed auricles intraoperatively. We improved the surgical procedure to achieve a good postoperative auricle position. Nine patients were included in this study. All patients underwent subtotal removal of the temporal bone and resection of the external auditory canal while preserving most of the external ear, and lateral skull base reconstruction was performed with anterolateral thigh flaps. We invented a new device, the auricle localizer, to select the correct position for the replaced external ear. The head skin incision line and two points of three-point pin fixation were used as criteria, and a Kirschner wire was shaped as a basic line to match these criteria. Another Kirschner wire was shaped by wrapping it around the inferior edge of the external ear as the positioning line, and these two lines were then combined. To evaluate the postoperative auricle position, the auricle inclination angle was measured using head frontal cephalogram imaging. The external ear on the affected side clearly drooped postoperatively in nonlocalizer cases, whereas this was not obvious in localizer cases. Auricle inclination angles 1 year after surgery significantly differed between these two cases (P = 0.018). The surgical device, the auricle localizer, is useful for selecting intraoperative accurate auricle positions. The assessment index, the auricle inclination angle, is useful for quantitatively evaluating postoperative results. 4 Laryngoscope, 2018. © 2018 The American Laryngological, Rhinological and Otological Society, Inc.

Do agility and skull architecture influence the geometry of the mammalian vestibulo-ocular reflex?

PubMed

Jeffery, Nathan; Cox, Philip G

2010-04-01

The spatial arrangement of the semicircular canals and extraocular muscles of the eye has been of considerable interest, particularly to researchers working on adaptations of the vestibulo-ocular reflex. Here we offer the first, extensive comparative analysis of the spatial relationships between each extraocular muscle and the canal providing its primary excitatory stimulus. The sample consisted of 113 specimens, representing 51 extant mammalian species. Hypotheses tested included that variations in the spatial alignments are linked with differences of skull morphology and with differences of agility during locomotion. Internal morphologies were visualized with magnetic resonance imaging and were measured with landmark-based vectors and planes. Values for body mass and agility were taken from the existing literature. Data were investigated for trends and associations with standard bivariate and multivariate statistical methods as well as with phylogenetically adjusted bivariate methods. The findings clearly show that species differences in the alignment of each extraocular muscle relative to the canal providing its primary excitatory stimulus are closely associated with changes of orbit morphology. The results also indicate that the actions of the oblique muscles interchange with those of the superior and inferior recti muscles when comparing lateral-eyed (rabbit) with frontal-eyed species (cat). There was only weak evidence to support the notion that canal-muscle alignments differ significantly among species according to how agile they are. The results suggest that semicircular canal morphology is arranged primarily for detecting head movements and then secondarily, if at all, for diminishing the burden of transforming vestibulo-ocular reflex signals in the most agile species.

The evolution of the complex sensory and motor systems of the human brain

PubMed Central

Kaas, Jon H.

2008-01-01

Inferences about how the complex sensory and motor systems of the human brain evolved are based on the results of comparative studies of brain organization across a range of mammalian species, and evidence from the endocasts of fossil skulls of key extinct species. The endocasts of the skulls of early mammals indicate that they had small brains with little neocortex. Evidence from comparative studies of cortical organization from small-brained mammals of the six major branches of mammalian evolution supports the conclusion that the small neocortex of early mammals was divided into roughly 20–25 cortical areas, including primary and secondary sensory fields. In early primates, vision was the dominant sense, and cortical areas associated with vision in temporal and occipital cortex underwent a significant expansion. Comparative studies indicate that early primates had 10 or more visual areas, and somatosensory areas with expanded representations of the forepaw. Posterior parietal cortex was also expanded, with a caudal half dominated by visual inputs, and a rostral half dominated by somatosensory inputs with outputs to an array of seven or more motor and visuomotor areas of the frontal lobe. Somatosensory areas and posterior parietal cortex became further differentiated in early anthropoid primates. As larger brains evolved in early apes and in our hominin ancestors, the number of cortical areas increased to reach an estimated 200 or so in present day humans, and hemispheric specializations emerged. The large human brain grew primarily by increasing neuron number rather than increasing average neuron size. PMID:18331903

Use of Performance Measures to Evaluate, Document Competence and Deterioration of Advanced Surgical Skills Exposure for Trauma (ASSET) Surgical Skills

DTIC Science & Technology

2015-03-01

71(2):193- 7. 13. Lobel DA, Elder JB, Schirmer CM, Bowyer MW, Rezai AR. A novel craniotomy simulator provides a validated method to enhance...MW, Rezai AR. A novel craniotomy simulator provides a validated method to enhance education in the management of traumatic brain injury...comparisons are significant at pɘ.05 - Wilcoxon matched pairs) A Specialty 0 5 10 15 20 Thoracotomy in ED Repair/ Drainage Hapatic Lacs- Open Neck exploration